Cutting back on Treatment for PTSD

As I wrote about a couple of months ago, the costs of treating post-traumatic stress disorder among American veterans are growing at the same time some beging to question the validity of some veteran's claims. An article in the Washington Post and an op-ed in the NY Times highlight both sides of this issue. In the Post we learn that many veterans of Iraq are seeking treatment for PTSD:

More than one in three soldiers and Marines who have served in Iraq later sought help for mental health problems, according to a comprehensive snapshot by Army experts of the psyches of men and women returning from the wars in Iraq, Afghanistan and other places.

The accounts of more than 300,000 soldiers and Marines returning from several theaters paint an unusually detailed picture of the psychological impact of the various conflicts. Those returning from Iraq consistently reported more psychic distress than those returning from Afghanistan and other conflicts, such as those in Bosnia or Kosovo.

Beyond concern for the health of our soldiers, there's concern over how we're going to pay for the treatment:

The new report comes at a time when budget constraints are causing worries about the cost of caring for large numbers of veterans seeking help for mental problems; the Department of Veterans Affairs is already contending with a recent surge in demand for help with PTSD from troops whose combat experiences go as far back as the Vietnam War or World War II.

Dr. Satel, a psychiatrist and resident scholar the American Enterprise Institute who is mentioned in the article I profiled in December, thinks the solution is more rigorously testing for fraudulant claims of PTSD, and skepticism for older veterans who are filing claims late in life:

As the department tries to distinguish among these groups, verification of exposure to trauma is vital. The inspector general's office found that for one-quarter of Vietnam veterans claiming post-traumatic stress, the department could not confirm any incidents of traumatic stress. A study in a leading psychiatric journal last year could not verify such history in 59 percent. True, military personnel records are not perfect — a cook who endured a terrifying rocket attack on an airbase at which he was stationed may be unable to produce documentation of it. However, such records could indeed disprove the fabrications of a cook who claimed he was traumatized by a firefight on infantry patrol.

Someday, the diagnostic techniques may be sophisticated enough to help us parse the varieties of claimants; but for now we must be skeptical of veterans who file claims as retirement approaches. The Veterans Affairs Department should be spending its time and money helping our newest veterans now, when the psychological consequences of war have fresh meaning and patients have an excellent chance at recovery. Decades after a war is too late to make sense of post-traumatic stress disorder.

I think it's safe to say that Dr. Satel's problem is not with the mere treatment of PTSD, but the fact that the Dept. of Veterans Affairs currently errs on the side of caution, whereas she would put the burden on the veteran to show that he either did suffer PTSD, or suffered a traumatic event that could lead to PTSD. That sounds all well and good at first, but her reasoning is inconsistent. On the one hand she says that there are in fact instances of PTSD "reactivating" in older veterans, but instead of using that call for more research regarding this phenoemon, she argues instead that we should be skeptical of older veterans who present claims of PTSD decades after their service. She's especially skeptical of baby boomers hitting retirement age, and yet as the American Psychological Association reported back in 1998, "clinical encounters [with delayed onset PTSD] abound":

• Terence Keane, PhD, director of the National Center for PTSD’s behavioral science division in Boston, first encountered the phenomenon in 1989 when a Navy veteran walked into his office a few days after a highly publicized explosion on the USS Iowa battleship.
• Mary Summers, PhD, a former VA psychologist in Augusta, Ga., recalls several older veterans who came into her office wondering why they were only recently having nightmares, sleeplessness and agonizing memories of their war experiences. A 72-year-old man, for example, had fought in World War II, Korea and Vietnam, but was never diagnosed with PTSD until after his wife died and he became plagued with memories of fellow soldiers’ deaths.
• Nadine Shigezawa, a VA psychologist in Honolulu, treats veterans who experienced some of the most traumatic events of World War II. Among her clients are survivors of the surprise attack on Pearl Harbor.

Surely these men are not concerned about their retirement income. And if their symptoms coincide with retirement, should that be cause for suspicion? Perhaps not:

And Schnurr is investigating the effects retirement has on veterans. She’s using data from the VA’s Normative Aging Study, a longitudinal project involving more than 2,000 men, tracked since the 1960s. She’s looking at how men who were exposed to combat function before and after retirement to see if the retirement experience sparks the development of troubling combat memories.

In fact, Schnurr suspects that, for some veterans, retirement may better predict the onset of PTSD than the aging process itself. She remembers encountering a woman whose husband, a Vietnam Veteran who had recently retired from the New York City police force, was developing PTSD symptoms.

Dr. Satel claims to be concerned that these unsubstantiated claims of PTSD are taking away valuable resources from veterans who are returning from Iraq and need the care now. As the Post reports, a significant number of soldiers are returning from their experiences in Iraq with symptoms of PTSD. And yet it's just as easy to argue that not enough soldiers are being treated for PTSD. From the Post:

Experts cautioned, however, that they do not have good ways to predict how many people will need help over time. Researchers have found that nearly two-thirds of Iraq veterans who "screened positive" for PTSD and other psychiatric disorders are not receiving treatment.

And this from the article I profiled back in December:

A far bigger problem is the many veterans who seek help but do not get it or who never seek help, a number of experts said. Studies have shown that large numbers of veterans with PTSD never seek treatment, possibly because of the stigma surrounding mental illness.

To me it is clear that the proper course of action is not to attempt to stigmatize with suspicion old soldiers who years after their trauma, are seeking help. This will make it more difficult not only for them but also for current veterans-many of whom already worry about the stigma attached to "mental illness"- to seek treatment. I do not argue that improperly diagnosed PTSD is not a problem. I will admit that in fact there may be some veterans who fraudulantly claim to be suffering from PTSD, and there may be those who think they are suffering from PTSD but perhaps are not, or are not suffering as much as other veterans. But what I see before me is evidence that in fact PTSD is a much more wide-spread problem than it would appear from the soldiers seeking treatment, as well as evidence that it can manifest itself long after the traumatic experience, well beyond retirement and into old age. To me that indicates that more studies of this phemomenon are required, and that until we can differentiate types of PTSD more effectively and treat them according to their severity appropriately, we should err on the side of caution and treat soldiers who are suffering even long after they've served, and not greet them "skepticism" or suspicion. Actually, it's pretty simple. If you go to war, you take care of the men who've served, and if we have to pay for some vets who aren't properly suffering, than that's a small price to pay for all of those who are.