Government Can Do More to Treat Veterans with PTSD

The murder of American Sniper author Chris Kyle at a Texas gun range by a fellow vet said to be suffering from Post-Traumatic Stress Disorder (PTSD) has restarted a national conversation about PTSD and raised questions about whether the government is doing enough to identify and treat those suffering from the condition.

Kyle’s killer, Eddie Ray Routh, had only recently been diagnosed with PTSD, according to his brother in law, but had a history of mental illness over the last several years. While details remain sketchy, it is possible that Kyle, who had dedicated his life to helping returning warriors with PTSD and other problems in adjusting, made a tragic mistake in bringing Routh to the gun range. Kyle may have been trying his own version of “exposure therapy” — a treatment option for PTSD sufferers where the clinician takes the patient back to the trauma and has him relive it repeatedly and, “ideally, with each retelling of what happened, the event would seem gradually less threatening.” Psychiatrist Albert Rizzo told the CNN:

“What happened this weekend with the death of former Navy Seal sniper Chris Kyle at a gun range is exactly the opposite of the evidence-based approach to treating PTSD,” termed ‘prolonged exposure’ or ‘virtual reality exposure’ therapy, he said. “Chris Kyle, while well trained in his field, had no clinical training in conducting therapeutic exposure.”

It is never advisable to put someone with PTSD in an environment where there is likely to be uncontrolled exposure to provocative events — such as gunfire and visuals of people shooting guns — because this could stoke a flashback in the PTSD sufferer.

The use of virtual reality in therapy shows how the government and military are light years ahead of how PTSD was viewed after the Vietnam War, when the military determined that ” if the problem lasted more than six months after the soldiers returned home, then it obviously was a pre-existing condition and had nothing to do with their wartime service.” At that time, PTSD was known as “stress response syndrome,” and the military’s shameful determination that our veterans were suffering from a condition unrelated to their combat experience condemned tens of thousands of vets who desperately needed help to a nightmare existence that many still suffer from today.

The issue with the government’s response to PTSD today is that, put simply, the problem is bigger than anyone imagined a few years ago and potentially as large as the number of PTSD cases for Vietnam vets. A study in 1993 found that more than 830,000 Vietnam veterans suffered from symptoms related to PTSD to one degree or another upon returning home.

Last year, the VA reported that through September 2011, more than 247,000 veterans of the Iraq and Afghanistan wars had been treated for PTSD. But according to the PTSD Foundation of America, that number represents less than 40% of our veterans who need help. A veteran’s own personal code of conduct that refuses to allow him to acknowledge “weakness” and a military culture that stigmatizes PTSD sufferers have contributed to some startling — and worrisome — statistics.

There were a record 349 suicides of active duty personnel in 2012. Nearly two in three marriages of PTSD sufferers end in divorce. The inability of the PTSD patient to hold a job has contributed to an epidemic of homelessness among combat veterans. It is estimated that one in three returning vets will exhibit at least some of the symptoms of PTSD, with between 13-20% of vets needing psychiatric care.

A companion condition to PTSD — Traumatic Brain Injury (TBI) — is also a mental health problem, given the large number of soldiers wounded in IED attacks. The condition presents itself in similar ways to PTSD and it’s estimated that between 4-9% of returning vets suffer from TBI.

Suicidal thoughts, alcoholism and drug abuse, waking nightmares, insomnia, losing contact with reality, and being transported back to the battlefield — the physical symptoms of PTSD are so debilitating that in severe cases it is possible that the victim will lash out violently. Whether Eddie Ray Routh suffered a terrifying flashback on the gun range or, as he told his sister, he simply “traded his soul for a new truck,” PTSD played a role in this tragedy, and advocates are worried that the media — ever looking to oversimplify — might stigmatize returning vets suffering from PTSD as crazed killers.

It’s happened before with vets returning from Vietnam. Several high-profile murders by mentally ill Vietnam veterans spawned a seeming frenzy in the press, with lurid stories of violent vets driven to kill by their “unique” experiences in Vietnam. Popular culture contributed mightily to the portrait of the murderous Vietnam veteran, as both films and television shows painted a picture of the moody, brooding ex-soldier who might explode into violence at any moment, and for no reason.

The stigma that attached to the Vietnam vet as a result of this media campaign prevented thousands from seeking needed treatment. Could it happen again? The media hasn’t changed much, but has society changed to the point that we can view PTSD with more understanding and perspective?

The U.S. government, after a slow start in the early part of the decade, has begun to gather and concentrate considerable resources to address the issue of PTSD-TBI in veterans returning from Iraq and Afghanistan. The latter part of the Bush administration and the entirety of the Obama administration has seen many changes in how the military identifies probable PTSD sufferers, and reforms in how benefits are dispensed have streamlined the process so that those diagnosed with PTSD can now get treatment more quickly.

In 2010, the president signed an executive order making it much easier for veterans from any war to get treatment for PTSD and claim disability benefits. Now, all the veteran needs is for a doctor to confirm a diagnosis of PTSD for the patient to receive benefits. Previously, the process was far more involved and could take years for a case to be resolved.

The amount of resources devoted to mental health at the VA has increased substantially. For FY 2012, the president requested $7.2 billion to fund a variety of PTSD and related programs, including research, substance abuse, suicide prevention, and treatment of PTSD-TBI patients. This represents a 15% increase in funding over last year. The Defense Department plans on spending $1.2 billion itself on research and other programs related to PTSD.

The VA has hired more than 5,000 mental health professionals in the last two years, bringing the total in the agency to over 22,000. They have also added personnel to deal with the avalanche of disability claims, although the waiting period is still measured in years at some VA facilities. Nationwide, the average is about nine months.

VA officials say the money will also support:

collaborative programs with the Defense Department, including outreach to veterans, as well as new but unspecified types of treatment. It promises to lay the groundwork for psychological treatment “for many years to come.”

Outreach to veterans is key. Reducing the stigma of PTSD within the ranks is of paramount importance if those suffering from the condition are going to get well. Ron Capps retired in 2008 after a 25 year career in the Foreign Service and Army Reserve. His battle with PTSD was hampered considerably by his own martial code, and the code followed by his fellow soldiers:

In Army culture, especially in the elite unit filled with rangers and paratroopers in which I served, asking for help was showing weakness. My two Bronze Stars, my tours in Airborne and Special Operations units, none of these would matter. To ask for help would be seen as breaking.

But, finally, when in the middle of the day I was forced to hide, shaking and crying in a concrete bunker, railing against the noise and the images in my head, and when I understood that to continue was to endanger the soldiers I was sent to Afghanistan to lead, I asked for help.

Advocates say that Capps’ experience is not atypical. The Army has begun to train officers to recognize PTSD symptoms in their ranks, hoping early intervention can get help to the afflicted soldier quickly. Col Robert Saum, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, explains:

This training is ongoing, and [the Army] has introduced a program called Comprehensive Soldier Fitness. It addresses not just physical fitness, but mental health fitness to the NCOs and the officer corps. The buddy-buddy system of taking care of each other is one of the primary things that the program addresses.

There is also a move to screen all returning war veterans for PTSD-TBI once a year. All soldiers returning from the front are currently tested for PTSD, but this isn’t good enough because a patient might not become symptomatic for months or even years after combat. Hence, the annual tests will help in identifying those who need treatment.

But the VA is having enormous difficulty in treating the cases they have already. A document recently released by the VA reveals some of the difficulties the agency will face in the near future:

The document, which veterans groups have unsuccessfully filed Freedom of Information Act (FOIA) requests to obtain, shows that there are now a total of 1,634,569 veterans from post-9/11 wars, and that 745,481 of these veterans have filed disability claims, which is an astonishing 46 percent.

The document also shows that while the number of veterans who have been diagnosed by V.A. doctors with PTSD is 247,243, the number of them who are actually getting disability benefits is 137,911. In other words, 44 percent of post-9/11 veterans diagnosed with PTSD are still not getting their benefits.

This, despite the president’s executive order streamlining the process to receive disability benefits and speed treatment of PTSD to those who need it. Clearly, there are improvements to be made by this president and future presidents because this is a problem that will haunt the VA for decades to come. Ten-thousand Iraq and Afghanistan veterans every month are currently pouring into VA facilities across the country. Already stretched to the limit, the VA is going to have to greatly increase its resources if it is to meet the demand for treatment from our returning veterans.

With combat operations over in Iraq and winding down in Afghanistan, the number of PTSD cases will probably tail off — even though being deployed to either of those countries is still no picnic. The government, while improving its response to this crisis, is still not doing enough. More money can be found, more doctors and clinicians hired, more staff brought on to deal with the crush of benefit applications — this is the easy part. All it takes is the will in the White House and the Congress to face the problem and meet the demand.

But changing the culture in the military that stigmatizes those who seek help for mental health problems is an entirely different matter. As with other institutional problems in the military, it will take time to alter fundamental perceptions about PTSD. It will also be difficult to instill confidence in the ranks that seeking help will not hinder a soldier’s career.

That is the greatest challenge facing the government and the military as our warriors return home with no visible scars of their combat experience, but needing help to battle their own personal demons that haunt their days and make their nights a living hell. And the tragedy is that PTSD is treatable — if only those who need help the most request it and the government charged with looking after them can respond humanely and in a timely manner.