"The war. It's what happened to me in the war. I could never get over it. But I learned to live with it. Then all of a sudden on my 60th birthday it became a terrible weight. I couldn't put it out of mind. I feel so very depressed about it. Sometimes I sit for hours, brooding over the past."
So begins Wilbur Cohen's account of his own suffering in Arthur Kleinman's wonderful book What Really Matters. (1) Mr. Cohen had been in hand-to-hand combat in the Pacific theatre in World War II. After the war he had gone to college, become financially successful, and raised a family. Only after he had fulfilled his responsibilities as an adult did his profound sense of horror about the war return.
Mr. Cohen's experience is not unique. Old psychic wounds re-emerge for many veterans as they age. But older veterans with mental health needs have not received nearly as much attention as the men and women who have been deployed in the wars in Iraq and Afghanistan.
This is entirely understandable. Veterans of our nation's current wars often suffer terribly and deserve all the support that our nation can muster. But the fact of the matter is that veterans of these recent wars make up only 10-15 percent of our nation's veterans. Currently, more than 50 percent of veterans are 60 or older, and about 45 percent are 65 or older. The Department of Veterans Affairs (VA) projects that these proportions will continue at least until 2035. (2)
Unfortunately, like veterans of recent wars, older veterans are a higher risk than the general population for mental disorders, including:
• Depression, the prevalence of which may be double that of older adults who are not veterans. (3)
• Post-traumatic stress disorder (PTSD), which can continue for years or can re-occur in old age. (4)
• Suicide. Older veterans appear to have a suicide rate 50 percent greater than older adults who did not serve in the military. (5)
Those with PTSD are also at heightened risk for dementia. (6) Like all people disabled by dementia, veterans rely heavily on family members for care and support. And they, like all family caregivers, are at high risk of social isolation, depression, and anxiety. (7)
In addition to being at risk for diagnosable mental disorders, older veterans are risk for Late-Onset Stress Symptomatology (LOSS). According to the National Center on PTSD, "Many older veterans have functioned well since their military experience. Then later in life, they begin to think more or become more emotional about their wartime experience. " (8)
Treatment Works -- When Used
Treatment of depression and other affective disorders as well as of anxiety disorders, including PTSD, is often effective for veterans as for those without military experience. In addition, new models of treatment are emerging for veterans. For example, Translating Initiatives for Depression into Effective Solutions (TIDES) "has shown impressive results with eight out of ten veterans effectively treated in three VA regions." (9)
Unfortunately, a recent study of depression treatment of older adult veterans concluded, "The odds of receiving depression treatment decreased with increasing age ... Many depressed older [veterans] may have limited or no treatment." (10)
VA Initiatives for Older Veterans
Over the past few years, the VA has significantly increased its efforts to respond to the mental health needs of veterans, with particular attention to those returning from Iraq and Afghanistan. Older veterans have benefited from these efforts to prevent suicide, to increase accessibility to treatment, to use evidence-based treatments, and to build delivery systems that integrate physical and behavioral health services.
In addition, the VA has undertaken several initiatives that are specific to older veterans, especially the integration of mental health providers on home-based primary care teams, in the VA's long-term care centers, and in hospice and palliative care settings, spinal cord injury centers, and rehabilitation centers for the blind. (11)
Promises to Keep: Criticism of VA Initiatives for Older Veterans
Despite the VA's substantially stepped up efforts to expand and improve mental health care for older veterans, advocates for veterans such as Vietnam Veterans of America and Veterans for Common Sense maintain that the VA is not moving quickly enough. They note, for example, that the VA's increase of services and staff has not kept pace with increasing need (12) and a VA investigation revealed the VA does not consistently live up to its policy requiring rapid evaluation and treatment planning for veterans requesting mental health services. (13)
The VA Cannot Do It Alone
But the VA cannot do the whole job. Some 70 percent of veterans do not use the VA for their health care. There are many reasons for this -- limited eligibility, not being in priority populations, distance to VA centers, dissatisfaction with service in some facilities, etc.
But it's not just inadequate capacity and resources in the VA that keeps many veterans away. Many have returned to civilian life, to work and family, and they want to get their health care from local health and mental health providers. Unfortunately, many of these providers are simply not prepared to deal with the special issues that older veterans bring to them. (14)
What Needs to Be Done
In addition to increasing the pace of expansion and improvement of the VA's mental health services, efforts need to be made to insure that older veterans as well as veterans of current wars benefit, including:
• Outreach to older veterans designed to overcome the stigma, which is a barrier to the use of services that are available.
• Increased support and training for primary care and mental health providers in the community regarding the culture and special needs of older veterans.
• Enhanced support for family caregivers.
Most importantly we need to acknowledge, thank, and honor our older veterans for their service and sacrifice and assure them that our nation will stand by them throughout their lives.
Asley Milco, a student at Columbia University School of Social Work, provided research assistance for this post.
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.
(1) Kleinman, A. "Chapter 2: Winthrop Cohen" in What Really Matters: Living A Moral Life Amidst Uncertainty and Danger. Oxford University Press, 2006.
(2) National Center for Veterans Analysis and Statistics. "Veteran Population Projections: FY 2000 to FY 2006." December 2010.
(4) Durai, et al. "Exposure to Trauma and Posttraumatic Stress Disorder Symptoms in Older Veterans...". Journal of the American Geriatrics Society, June 2011.
(5) Wood, Matt. "Crunching The Numbers on the Rate of Suicide Among Veterans" in Science Life, April 27, 2012.
(6) Qureshi SU, et al. "Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder." In Journal of the American Geriatrics Society, September 2010.
(7) Bass, D. et al. "Negative Caregiving Effects Among Caregivers of Veterans With Dementia". American Journal of Geriatric Psychiatry, March 2012.
(8) VA. "Aging Veterans and Post-Traumatic Stress Symptoms". Information on Trauma and PTSD. 12/20/2011
(9) National Alliance on Mental Illness. "Depression and Veterans Fact Sheet". October 2009.
(10) Burnett-Ziegler, et al. "Depression Treatment in Older Adult Veterans". American Journal of Geriatric Psychiatry, March 2012.
(11) Karlin, B. and Zeiss, A. "Transforming The Mental Health Care of Veterans in the Veterans Health Administration" in Generations, Summer 2010.
(12) Abramson, L. "VA Struggles To Provide Vets With Mental Health Care" National Public Radio. April 25, 2012.
(13) VA. "Veterans Health Administration: Review of Veterans Access to Mental Health Services" April 23, 2012.
(14) Karlin, B. and Zeiss, A. "Transforming The Mental Health Care of Veterans in the Veterans Health Administration" in Generations, Summer 2010.
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