Madam Speaker, another four soldiers died today in Iraq. Families mourn the loss of loved ones. Our Nation mourns the loss of brave soldiers. Over 900 Americans have died in Iraq so far. As many as 10 times that number have been injured.…
Madam Speaker, another four soldiers died today in Iraq. Families mourn the loss of loved ones. Our Nation mourns the loss of brave soldiers. Over 900 Americans have died in Iraq so far. As many as 10 times that number have been injured. Americans spent $150 billion, and we know tens of billions dollars more will be spent this year. If only one soldier had died, the number would be too high, but the casualties and the grief are much worse.
The truth is we have not even begun to see the casualties of the Iraq war. The truth is that thousands of soldiers will face a lifetime of injury from the war. The truth is we will have not even begun to count the casualties that will come from post-traumatic stress disorder.
The magnitude of the coming casualties among returning U.S. soldiers is staggering. The prestigious New England Journal of Medicine in its most recent issue, which I will enter into the Record, gives a glimpse into the coming medical crisis facing our soldiers, families, and the Nation. The journal is known for credibility, thoughtful and factual reporting and analysis. The journal conservatively estimates that one in five soldiers will be afflicted with PTSD. In many cases, the symptoms will not even surface for a year or more. The casualties from the President's war of choice will affect tens of thousands of soldiers. There are 160,000 soldiers in Iraq today. Using the journal's conservative estimate, 30,000 U.S. soldiers will become post-traumatic stress disorder casualties in this war. Most do not even know that they are sick yet. Most do not exhibit any symptoms outwardly and will not for months or years. Tragically, when symptoms do appear, many soldiers will not ask for help.
Call it the tough-guy stigma. Soldiers are trained to be fearless no matter what the danger. Too many consider it a sign of weakness to need help. They will try to suffer in silence, but PTSD is as powerful as an artillery shell. Without help, PTSD can tear too many brave military men and women to shreds psychologically. I know. I was a Navy doctor and psychiatrist who treated soldiers returning from Vietnam with the post-traumatic stress disorder. Gut-wrenching is the only polite way to describe the anguish and suffering these soldiers experienced. Many of them still struggle against the demons of this disease.
As a doctor, you can do everything you can to help. All too often it is not enough, and all too often the only thing you can do is comfort the afflicted. You realize just how inadequate modern medicine is.
Some wonder why I strongly oppose the President's war of choice. Because I have seen the casualties. I have seen the pain inside the mind that no bandage can cover. I have treated the wounded, only to know in the dead of night just how little I and every doctor could do. We wanted to end the suffering. Who would not? We wanted to heal their wounds. Who would not?
Years later, long after the Vietnam War, years later after the media moved on to other issues, PTSD was still there haunting soldiers' minds. I saw it when I was a doctor working and treating prisoners in the King County jail. They include former soldiers who got into trouble because they struggled keeping their emotions under control. They struggled with PTSD. People who had served their country with no prior history of mental illness suddenly found themselves on the wrong side of the law. Were they felons or fallen heroes in need of help? I know what I think.
PTSD preys on the peace and happiness every American deserves, especially those who were drafted to fight in a war which this country came to loathe. After Vietnam, soldiers did not even have the thanks of a grateful Nation. We blamed them for the government's arrogance. It took decades before the wounds of the Nation began to heal. Thousands of names on a wall made us realize how much we had lost, how little we had gained, and how wrong it all was.
At least today America honors our soldiers, even as the opposition to the President's war grows. And it should. We are just beginning to realize the consequences of the President's war of choice. America has about 10,000 soldiers already dead or wounded. We face another 30,000 casualties. The wounds have already been inflicted. They are just not visible yet.
And they wonder why I strongly oppose the President's war of choice. The administration keeps inventing new reasons why we had to invade Iraq. They cannot even explain why 10,000 have already suffered or why 30,000 more will.
This is not about my opposition to the war, though. This is about preparing to help the men and women coming home from war. This is about
honoring our soldiers by facing the truth about the coming wave of casualties here at home from PTSD. This is about a call to action in every city and town across America and in every home and every workplace. We must help them.
This is about a call to action in every city and town across America, in every home, in every workplace, PTSD is as real, as painful, as devastating as any shrapnel wound. If the effects could be seen like a bullet wound, we'd race the patient to the hospital for immediate care.
But PTSD doesn't work that way. It's silent. It's almost invisible. It's a war raging inside a person and we have to help. We can help by debunking the tough guy stigma. We can help by talking, listening and watching for signs of stress as our loved ones come home. We must help by demanding that the Veteran's Administration receives the funding to treat our returning soldiers. It's not a one-year supplement.
It is the recognition of the long-term consequences of the Iraq War. It is the commitment to treat our soldiers afflicted with PTSD with the best possible care for as long as necessary--and it will be years for many.
Every night the evening news graphically shows us the latest casualties and consequences of this war. It's awful. It didn't have to happen. And the overwhelming number of casualties are ahead of us, not mission accomplished. Before it is over, Iraq's casualties will top 40,000 U.S. soldiers. For what? Nothing at all.
[From The New England Journal of Medicine, July 1, 2004]
Acknowledging the Psychiatric Cost of War
(By Matthew J. Friedman, M.D., Ph.D.)
The date presented by Hoge and associates in this issue of
the Journal about members of the Army and the Marine Corps
returning from Operation Iraqi Freedom or Operation Enduring
Freedom in Afghanistan force us to acknowledge the
psychiatric cost of sending young men and women to war. It is
possible that these early findings underestimate the eventual
magnitude of this clinical problem. The report is
unprecedented in several respects. First, this is the first
time there has been such an early assessment of the
prevalence of war-related psychiatric disorders reported
while the fighting continues. Second, there are
predeployement data, albeit cross-sectional, against which to
evaluate the psychiatric problems that develop after
deployment. Third, the authors report important data showing
that the perception of stigmatization has the power to deter
active-duty personnel from seeking mental health care even
when they recognize the severity of their psychiatric
problems. These findings raise a number of questions for
policy and practice. I focus here on post-traumatic stress
disorder (PTSD), because there is better information about
this disorder than about others and because PTSD was the
biggest problem noted in the responses to an anonymous survey
among those returning from active duty in Iraq or
Afghanistan.
The rigorous evaluation of war-related psychiatric
disorders is relatively new, having begun with the National
Vietnam Veterans Readjustment Study. This national
epidemiologic survey of male and female veterans of Vietnam
was conducted in the mid-1980s. The veterans were therefore
assessed 10 to 20 years after their service in Vietnam. The
prevalence of current PTSD was 15 percent among men and 8
percent among women. The lifetime prevalence of PTSD was
higher--30 percent among male veterans and 25 percent among
female veterans.
A retrospective cohort study of veterans of the Gulf War
that was conducted between 1995 and 1997 showed a prevalence
rate of 10.1 percent for PTSD among those who had experienced
combat duty, in contrast to a prevalence rate of 4.2 percent
in a matched cohort of Gulf War-era veterans who had not seen
combat. The adjusted odds ratio for PTSD for those who had
been in combat was 3.1; this is similar to the odds ratios in
the present study of 2.84 for soldiers and 2.66 for Marines
after deployment to active duty, as compared with soldiers
before deployment.
In a longitudinal study of New England veterans of the Gulf
War, the prevalence of PTSD more than doubled between the
initial assessment performed immediately after their return
to Fort Devens, Massachusetts, and the follow-up assessment
performed two years later. The rates increased from 3 percent
to 8 percent among male veterans and from 7 percent to 16
percent among female veterans. Higher levels of symptoms have
been reported among members of the National Guard and the
Reserves than among active-duty personnel.
Finally, a retrospective survey of American male and female
soldiers deployed to Somalia between 1992 and 1994 showed an
estimated prevalence of PTSD of approximately 8 percent, with
no difference according to sex. When the focus of this
mission shifted from a United Nations' humanitarian
peacekeeping operation to a more traditional military
deployment to subdue to Somali warlords, there was greater
exposure to traumatic situations and a higher prevalence of
PTSD among the American troops.
It is unclear at this time whether the prevalence of PTSD
among those returning from Operation Iraqi Freedom or
Operation Enduring Freedom will increase or decrease. On the
one hand, it is encouraging that the Department of Defense
has been active in providing mental health care in the war
zone and psychiatric resources in the United States and has
demonstrated a commitment to monitor psychiatric disorders,
as reflected by the present report. Furthermore, the findings
of the National Vietnam Veterans Readjustment Study suggest
that considerable recovery for PTSD among veterans is
possible, as shown by the difference between the lifetime and
the current prevalence of this disorder.
On the other hand, the National Vietnam Veterans
Readjustment Study cannot tell us whether the onse of PTSD
occurred while Vietnam veterans were still in uniform or at
some time later, during the 10 to 20 years between their
exposure to war and the survey for the study. Indeed, there
is reason for concern that the reported prevalence of PTSD of
15.6 to 17.1 percent among those returning from Operation
Iraqi Freedom or Operation Enduring Freedom will increase in
coming years, for two reasons. First, on the basis of the
findings of the Fort Devens study, the prevalence of PTSD may
increase considerably during the two years after veterans
return from combat duty. Second, on the basis of studies of
military personnel who served in Somalia, it is possible that
psychiatric disorders will increase now that the conduct of
war has shifted from a campaign for liberation to an ongoing
armed conflict with dissident combatants. In short, the
estimates of PTSD report by Hoge and associates may be
conservative not only because of the methods used in their
study but also because it may simply be too early to assess
the eventual magnitude of the mental health problems related
to deployment to Operation Iraqi Freedom or Operation
Enduring Freedom.
A recent reanalysis of the data from the National Vietnam
Veterans Readjustment Study and the Hawaii Vietnam Veterans
Project suggest that after the development of PTSD, the risk
factors for persistent PTSD are ``primarily associated with
variables relating to the current time frame: current
emotional sustenance, current structural social support, and
recent life events.'' This information is clearly useful for
mental health policy and planning, because it raises the
hopeful possibility that PTSD may be reversible if patients
can be helped to cope with stresses in their current life.
There are obviously important distinctions between the
period after the Vietnam War and the present. Americans no
longer confuse war with the warrior, those returning from
Iraq or Afghanistan enjoy nation support, despite sharp
political disagreement about the war itself. In addition, the
field of study of PTSD has matured to the point where
effective evidence-based treatment and practice guidelines
are available for use by the Departments of Defense and
Veterans Affairs and by civilian mental health practitioners.
Cognitive--behavioral therapies have been successful in the
treatment of PTSD, and two selective serotonin-reuptake
inhibitors have been approved by the Food and Drug
Administration. Practitioners in the Departments of Defense
and Veterans Affairs are sophisticated and strongly motivated
to continue to improve their skills in treating PTSD.
Collaboration between mental health professionals in the
Department of Defense and those in the Department of Veterans
Affairs is at an all-time high. For example, the Veterans
Affairs National Center for PTSD and the Defense Department's
Walter Reed Army Medical Center collaborated to develop the
Iraq War Clinician Guide (available at www.ncptsd.org/topics/ war.html) and to conduct a multisite, randomized trial of
cognitive--behavioral therapy for PTSD among female veterans
and female active-duty personnel.
In the best-case scenario, active-duty, Reserve, and
National Guard personnel as well as veterans of Operation
Iraqi Freedom or Operation Enduring Freedom with symptoms of
PTSD will take advantage of the many mental health services
available through the Departments of Defense and Veterans
Affairs. Educational initiatives will be implemented to help
veterans and active-duty personnel recognize that the loss of
social support or the effect of recent adverse life events
may precipitate a return of the symptoms of PTSD. Veterans
and active-duty personnel will also be encouraged to monitor
their psychological health and to seek treatment if and when
it becomes necessary.
Alas, there is also a worst-case scenario that demands
immediate attention. Hoge and associates report that concern
about possible stigmatizaion was disproportionately greatest
among the soldiers and Marines most in need of mental health
care. Owing to such concern, those returning from Operation
Iraqi Freedom or Operation Enduring Freedom who reported the
greatest number of the most severe symptoms were the least
likely to seek treatment for fear that it could harm their
careers, cause difficulties with their peers and with unit
leadership, and become an embarrassment in that they would be
seen as weak.
These findings are consistent with those in an earlier
report that showed low use of mental health services among
Navy and Marine Corps personnel. In contrast to a rate of
28.5 percent among male civilians with a psychiatric disorder
who sought
treatment, only 19 percent of servicemen with a psychiatric
disorder sought treatment, Furthermore, among military
personnel with PTSD, the rate of seeking treatment was only
4.1 percent, which is substantially lower than that for other
psychiatric disorders. This finding may indicate that within
the military culture, ``succumbing'' to PTSD is seen as a
failure, a weakness, and as evidence of and innate deficiency
of the right stuff.
Hoge and associates suggests that the perception of
stigmatization can be reduced only by means of concerted
outreach--that is, by providing more mental health services
in primary care clinics and confidential counseling through
employee-assistance programs. The sticking point is
skepticism among military personnel that the use of mental
health services can remain confidential. Although the
soldiers and Marines in the study by Hoge and colleagues were
able to acknowledge PTSD-related problems in an anonymous
survey, they apparently were afraid to seek assistance for
fear that scarlet P could doom their careers.
Our acknowledgment of the psychiatric costs of war has
promoted the establishment of better methods of detecting and
treating war-related psychiatric disorders. It is now time to
take the next step and provide effective treatment to
distressed men and women, along with credible safeguards of
confidentiality.
Source Information
From the National Center for PTSD, Department of Veterans
Affairs, White River Junction, Vt.; and the Departments of
Psychiatry and Pharmacology and Toxicology, Dartmouth Medical
School, Hanover, N.H.