June is PTSD Awareness Month, so declares the Veterans Administration. Hundreds of thousands of war returnees from Iraq and Afghanistan have or will develop post-traumatic stress disorder. It is a condition that induces suffering in veterans -- and their families, who can be repeatedly separated from their loved one, live with more limited resources as a member is gone and emotionally contend with anxiety about the possible injury or death of their soldier.
The risk of developing PTSD is increased when military personnel experience combat, are wounded, witness death, are taken captive or tortured, handle remains, or are sexually harassed or assaulted. The most stressful of combat experiences include exposure to unpredictable attacks, including IEDs, sniper fire, and rocket-propelled grenades. Longer and multiple deployments as well as greater time away from base camp add to a soldier's likelihood of developing PTSD.
The Institute of Medicine/National Academy of Sciences issued "Treatment for PTSD in Military and Veteran Populations (Initial Assessment)" after reviewing Department of Defense and VA data on prevention, screening, diagnosis, treatment and rehabilitation of PTSD. Its aim was to inform and direct future efforts to more effectively respond to a condition that profoundly impacts soldiers, families, and our communities.
What Might PTSD Look Like in Your Family?
Your loved one was exposed to a life-threatening or horrific event, which may have happened in recent months or perhaps happened in the past -- even years ago. Your soldier becomes inward, isolated, and preoccupied, with difficulty concentrating on and completing tasks. He or she has changed profoundly, leaving you confused and even afraid. Some will startle very easily at something as minor as the sound of a door closing or a telephone ringing. Some will be highly vigilant, as if a sniper were on a rooftop nearby. If you can get the person to talk about what is happening, he or she may describe feeling scared, numb, or both. Images of the trauma erupt into the person's conscious mind, sometimes without a clear trigger. Sleep is terribly restless and full of anxious dreams. Alcohol and drug abuse is very common, and if a person smokes cigarettes he or she may smoke a lot more.
Suicidal thoughts are common. (In fact, the number of completed suicides among veterans of Iraq and Afghanistan now far exceeds the deaths suffered in combat.) A well-validated screening tool is the PTSD Checklist, a version of which exists for military personnel and can be accessed on the Web to help in identifying this condition.
Treatment of PTSD
We have much to learn about what are the most effective treatments for PTSD for which individuals and at what point in the course of their illness. A principle that applies to PTSD, as it does to every serious medical illness is that early detection and early intervention can help slow the progression of the disease. Another principle is that comprehensive treatment is essential: Interventions are often best when they combine medications, therapy, ongoing self care (exercise, nutrition, yoga and meditation), supportive friends and families, and control the use of alcohol and non-prescribed drugs. Still another principle is that treatment be continuous -- because interrupted treatment allows illness to gain the upper hand producing relapse (falling ill during an episode of illness) or recurrence (falling ill after recovery).
Studies indicate that the therapy treatments that work for PTSD are exposure therapy, cognitive behavioral therapy (CBT), anxiety management programs, and EMDR (eye movement and desensitization reprocessing -- a new finding given its unclear results in the past). It is critical to detect depressive illness and substance use disorder, highly common co-occurring conditions to PTSD, because unless these are recognized and treated a soldier cannot recover from the primary traumatic disorder.
Medication treatment has proven less clear, especially for the commonly used selective serotonin uptake inhibitors and serotonin reuptake inhibitors (SSRIs and SNRIs). Studies of U.S. veterans have yet to show conclusive efficacy, though there is considerable debate about this finding because of more sanguine findings with veterans in other countries. Findings about other antidepressant medications like tricyclics and monoamine oxidase inhibitors have been even less conclusive.
Complementary and Alternative Medicine (CAM) treatments show promise and include herbal compounds, yoga (especially breathing techniques), acupuncture, and meditative techniques. But here too the evidence is at best preliminary and contested.
What Can You Do?
It is not enough for doctors to ask "Why are you here?" Patients and families often wonder, "How will I be able to tell if the treatment is working?" So doctors need to ask their patients and their families what they want to achieve. If you are not asked, come prepared to say what that is. Establishing clear goals for treatment is a simple and practical way of determining if the treatment is working. In addition, the use of standardized questionnaires, simple checklists that quantify symptoms and functioning, like PTSD and depression scales, are also good ways of monitoring if a person is responding to treatment. While mental health disorders have yet to have blood tests, these paper and pencil scales are as reliable in determining treatment response as are blood sugar, hemoglobin A1c levels and lipid profiles.
Psychiatric conditions, including PTSD, depression and substance use, often have the additional vexing problem where those affected fight against receiving the care that can make a difference. Sometimes it is the illness itself that blinds a person from knowing they are ill. Stigma, shame, hopelessness that anything can help, bad experiences with care, not wanting to be a burden, and fear of unemployability as a result of mental illness (especially in uniformed personnel jobs like police, fire, and EMTs) all conspire to deter a person with PTSD from getting care. Sometimes this is the greatest problem a family will face.
Families will need to be clear about what they see in the person affected, validate their experiences with each other and ally together, listen to understand why the veteran is behaving as he or she is, and carefully use their leverage to help their loved one act, ultimately, in his or her interest. Families can learn how to best help their loved one, but they generally cannot do so without the support and coaching of others.
What We Can Do Now for Veterans and Their Families
The IOM report urges that PTSD screening be carried out at least once a year in primary care settings. Standardized screening is an important way to rise above a "don't ask, don't tell" policy of medical evasion by doctors and patients.
Families need to be an ongoing part of the treatment of war returnees with mental health conditions. While consent is always needed, it helps to create family involvement as an expectation of good treatment, not tack it on after the fact. The family may prove not only the best early warning system of danger but also can be the greatest asset a person with an illness may have.
We must measure the quality and outcomes of treatment programs to ensure that they are consistently providing the evidence-based practices (such as they are) and are producing results. We can evaluate program performance to determine patient retention in treatment so they have a chance at recovery.
We must also seek innovative and alternative treatments that may prove not only effective but more palatable to soldiers, their families, and even are less costly than conventional interventions.
What Lies Ahead
The IOM has also called for observing clinical services and practices on military bases as well as ongoing assessment of new and emerging treatments and practices. It speaks to an ongoing need -- and commitment -- to help veterans and their families recover from the "invisible" yet profoundly evident consequences of war on the minds and souls of combatants.
The fight ahead is not only to "wage war for peace," to paraphrase The Carter Center, it is also for the peace of mind of those individuals (and their families) who served and are serving in Iraq and Afghanistan.
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.
Dr. Sederer's book for families who have a member with a mental illness, The Family Guide to Mental Health Care is now available.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Dr. Galea is Chairman of the Department of Epidemiology at the Columbia/Mailman School of Public Health and Chair of the IOM Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder.
For more by Lloyd I. Sederer, M.D., click here.
For more on PTSD, click here.