Sunday, November 08, 2009

PTSD, A New Meaning

As all the talking heads agreed
Fort Hood was clearly now the locus
And a host of murders provided seed
But the Army was the focus
How could something go this wrong
When the rules were sharp and strong
And uniforms were clean and starched
So to all one drummer marched?
Well now we have reversed the order
And called it pre-traumatic stress disorder

The tragedy of 5 November 2009 at Fort Hood, Texas is less that the toll of lives was so high and more that the medical system for supporting combat soldiers may have been perverted to simply maximize the numbers available for combat (including the shooter). Essentially, there is close linkage between policies to maintain deployable numbers and the reality of PTSD (post traumatic stress disorder). There is no way for a soldier to maintain his/her sanity in a world of mindless commitment of the US military in repeated combat tours without the expectation that there will be serious breakage. We see the breakage in the suicide rates (75 in recent years at Fort Hood alone) and also in domestic abuse and substance abuse and a variety of antisocial behaviors. We have long recognized the effects of combat stress. Even the annals of the US Civil War demonstrate that the phenomenon is long with us. In years gone by, combat was usually better defined in the sense that more often than not, there were safe zones where the stresses of combat were greatly reduced. Units were sent to a rear area to refresh as well as resupply. Vietnam saw that change dramatically, but soldiers were still sometimes given R&R (Rest and Recuperation) to provide specific breaks from combat surroundings. Repeated tours in Vietnam were becoming more common as the war ended, but many soldiers experienced only a single tour. The wars in Iraq and Afghanistan brought additional deployment policy changes to the soldier in an era of a volunteer force. One good thing was that deployment became a unit move instead of individual replacements and this provided some amount of unit cohesion. Unfortunately, the gains achieved by increased cohesion were counter-balanced by far more frequent deployment. It takes time to recover from combat and the current OPTEMPO (tempo of combat operations) is more rapid than the recovery or restoration of the soldier.

While the reasons for the increase in PTSD are many, they include that our nation seriously underestimated the number of soldiers required for the invasion and occupation of Iraq and therefore the same units were repeatedly deployed. Qualification rules were relaxed so that older soldiers could enlist and the educational and “moral” requirements were also eased so that miscreants including some felons were welcomed to meet recruiting goals. On 12 December 2006, in a letter signed by Lieutenant General Kevin Kiley addressing the management of medical conditions and deployment considerations, the Commanding General of all Regional Medical Commands, made it clear that profiles limiting duty should only be made for physical reasons. “…Profile Codes, profiles may only address physical functional capacity and limitations.” While not an outright denial of psychiatric conditions such as PTSD, it goes further: “A psychiatric condition controlled by medication should not automatically limit deployment.” All this leads one to believe that the short term goals of reaching high deployable numbers outweighed the goal of a healthy Army in the field and at home. Let me ask the question differently. What good does a deployment screening center serve if the rules essentially mandate deployment?

The Army Medical Command’s letter is not the only evidence of medical management, although it highlights the Active Army goals. When the soldier has completed his duty, another agency takes responsibility for the diagnosis and care of the returning soldier/veteran. The VA (Veterans Administration) has been the lightening rod for criticism for care of veterans, and some of it is deserved. The VA has been at the forefront in automating medical records, but has been woefully under funded to treat growing numbers of veterans, especially given the increase in PTSD cases overall. Maybe a quick review of PTSD information will help the reader understand how complex the diagnosis and care can be on both the individual and on the national scale. First, numbers vary from a low of 10 % to over 30% based largely on the intensity of the combat experienced. This means that we have a wide range of estimates based on combat intensity, but that alone is insufficient. Intensity plus the duration of the exposure to stress is a common-sense yardstick. If you remain under stress longer, you are more likely to be adversely affected. There are other factors. If you have a history of alcohol or substance abuse, you are more likely to be affected. If you had a poor relationship with your father, you are more vulnerable. If you had behavioral or psychological episodes or problems or were in trouble with societal rules, you had increased likelihood of issues. If you lacked a support system, e.g., a family where you were respected and protected, then your chances for PTSD increased. We have not “calibrated” the effects of duration or repetition or family protection for the simple reason that each individual has a different tolerance level and some can take more stress than others. This complicates the evaluation by the VA and others. The VA, as many other agencies would do, has treated symptoms rather than the conditions that create or aggravate PTSD. It does not have the means to perform its mission let alone conduct preventive psychiatric care. Generally that means that the VA uses drugs to reduce the sleep interruptions and nightmares that accompany PTSD. That is also done under conditions of combat where psychotropic drugs have become common.

The VA maintains a National Center for PTSD that has created a Clinician’s Guide for Iraq War casualties and it contains a section entitled “Topics Specific to the Psychiatric Treatment of Military Personnel.” That document is 20 pages of policy and guidelines for the treatment of soldiers, but much as the active duty guidelines, the tone leads one to believe that the VA does not trust our soldiers to be telling the truth. Speaking of the responsibilities of military mental health officers:
“If evacuation is required, a replacement will not be forthcoming. Therefore, one must use common sense to screen out individuals who are ill or likely become ill. As anxiety is a normal response prior to deployment, normal fear and apprehension should not be pathologized. Clinicians must always maintain a keen eye for potential malingerers, as well.”
My personal experience in combat was quite the opposite. Soldiers would rather have suffered than be taken from their buddies to be treated for any medical condition. It would indeed be the exception that a soldier would seek treatment and if he/she did, the peer pressure might be unbearable. Soldiers might grouse about conditions, but they would rather grouse than leave the unit and let down their buddies. Additionally, there is a stigma associated with soldiers seeking help and especially for mental illness or emotional distress. My experience seems distant from the underlying assumptions that military medical professionals injected into their written policies and my experience was with an army that included draftees rather than all volunteers. Later when describing how to execute a Medical Evaluation Board, the VA again demonstrates a lack of trust:
“One has to be cognizant of the individual who may be attempting to manipulate the disability system in his or her favor by exaggerating symptoms, or seeking disability for conditions that are not medically unfitting. The psychiatrist must be mindful of all motivating factors and the potential for the influence of a disability seeking culture.” This damns all volunteers.
By one tally, the 184 Army and Marine Corps active duty suicides in 2008 amounted to 28% of its total of 469 casualties in combat (KIA) in Iraq and Afghanistan reported as of January 2009. That number did not include veterans returning from the wars, and yet we know that about 150,000 Vietnam veterans have committed suicide since that war ended. The current wars will not likely be any better. My point is, that with that number of suicides, it is inexcusable to hold a theory that a significant number of soldiers may be malingering. It is also ineffective medical policy and practice. Further, it would appear that the recruiting tail is wagging the dog. Inasmuch as the goal of maintaining combat strength of a volunteer force includes minimizing all injuries including self-inflicted injuries like suicide, then why would we logically stretch the “fit for combat” standard to insert the unfit into combat? Are we simply hostage to recruiting goals and unable to improve recruiting? Solving a recruiting problem on the backs of unfit soldiers is short sighted and stupid, at best, and potentially unethical for a profession that thrives on the Hippocratic oath: “First, do no harm.”

I am aware that the commander makes the final determination of fitness for combat, but any commander that does not consult with his/her medical professional is acting blindly and badly. We sense from reviewing the cited literature that the medical policy itself may contribute to the problem by a presumption of malingering and a dependence on psychotropic drugs to keep up the numbers for deployment.

My verse is literal in the sense that we have created a new affliction that I call: Pre-traumatic Stress Disorder. This is the sickness brought on by denying the reality of Post-traumatic Stress Disorder. Much Post-TSD is caused by Pre-TSD. If we recruit the shaky and then drug them for deployment and combat, we are asking for trouble and it is long-term trouble that will pale the Vietnam veteran experience. The two are intimately connected like dirty hands and typhoid except that dirty hands are sometimes visible. The cure is the political will to do the right thing and the options include:
We can keep fighting wars with volunteers and fully recruit to fill the deployment needs; we can cut down the wars and fight only the ones we have recruited for; we can give up on a volunteer force and return to the draft, then simply draft to the need of the wars we fight.

These are priorities that must be set and the Rumsfeld notion that wars are “come as you are parties” is obviously not going to work. Do we have the political will to set a budget that allows for effective recruiting and screening of volunteers? Do we have the courage to admit failure in a policy and change our ways? Do we have the courage to be absolutely ethical in employment of soldiers? (Is it any wonder that returning soldiers use excessive drugs and alcohol when they were prescribed for combat?)
In 2008, the Rand corporation estimated that 20% of returning soldiers had PTSD and the suicide rate of veterans is expected to be higher than the casualty rate of KIA (as is true for Vietnam Veterans where, through suicide, we are losing nearly 3 times the number KIA ).

At Fort Hood where the latest tragedy happened, 75 soldiers have committed suicide since 2003 and 10 this year alone of 114 suicides tallied among active soldiers and marines. Without characterizing the act of Major Hasan as willful terrorism and/or the result of mental illness, the wake up call was missed long ago as we stonewalled the question of fitness and refused to face the reality that PTSD has a beginning, but no end. Fort Hood alone has accounted for as many suicides in the past 6 years as 6 times the number killed by Hasan at that post. We sorrow over those murdered by an insane zealot and yet ignore the invisible fallen to suicide. We have little control over zealots except to root them out and to deny them positions of trust, but we need new policies to minimize suicide. Control begins with good policy and it continues with caregivers in the military and in the VA. It never ends. Pre-TSD is an excuse for bad policies and like all other excuses, it offers no help or hope for change. Not incidentally, I must ask if Hasan was sent to fort Hood to fill a quota much as our soldiers who are sent to combat again and again? As the song “Where have All the Flowers Gone?” popular in the 60s says: “When will they ever learn?”

George Giacoppe
09 November 2009

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