Sunday, March 20, 2005

Veterans and PTSD;
Focus on Women Veterans

Why is Mommy Like She Is? by Patience Mason.

The children of five Mommies with PTSD from different experiences talk about PTSD with their counselor. Same message, it is not your fault. A book for the children of women with PTSD.Describes the symptoms of PTSD in simple terms and reassures children that it is not their fault.

It seems unfortunate that we would have to have a book that explains to kids why their mom is having problems such as PTSD.  The book, though, was not written because of the current Iraq war.  It was published in 1994, so presumably it was written in response to the first Gulf War, or perhaps it pertains to civilian trauma.  In any case, in 1994, the problem was no so great as it is now. 

The two-year anniversary of the start of the Iraq war has led to media attention for the welfare of veterans.  An article in today's Chicago Tribune illustrates the current magnitude of the problem:
Stresses of battle hit female GIs hard
VA study hopes to find treatment for disorder

By Kirsten Scharnberg
Tribune national correspondent
Published March 20, 2005

NEW YORK -- On a mission just south of Baghdad over the winter, a young soldier jumped into the gunner's turret of an armored Humvee and took control of the menacing .50-caliber machine gun. She was 19 years old, weighed barely 100 pounds and had a blond ponytail hanging out from under her Kevlar helmet.

"This is what is different about this war," Lt. Col. Richard Rael, commander of the 515th Corps Support Battalion, said of the scene at the time. "Women are fighting it. Women under my command have confirmed kills. These little wisps of things are stronger than anyone could ever imagine and taking on more than most Americans could ever know."

But today, two years after the start of an Iraq war in which traditional front lines were virtually obliterated and women were tasked to fill lethal combat roles more routinely than in any conflict in U.S. history, the nation may be just beginning to see and feel the effects of such service.

Thousands of women, like the male veterans of so many wars before, are returning home emotionally damaged by what they have seen and done. These female troops appear more prone to post-traumatic stress disorder, or PTSD, than their male counterparts.

And studies indicate that many of these women suffer from more pronounced and debilitating forms of PTSD than men, a worrisome finding in a nation that remembers how many traumatized troops got back from Vietnam and turned to drugs and violence, alcohol and suicide. [...]
The article goes on to say that eight to ten percent of female active-duty and veteran soldiers develop PTSD.  Later in the article, they quote a New England Journal of Medicine article that reports PTSD in 17% of military personnel returning from Iraq.  At first glance, this would seem to contradict the assertion that PTSD is more common in female soldiers than in men.  The Tribune does not say which NEJM article they used to get the 17% figure; however, it probably was the editorial, Acknowledging the Psychiatric Cost of War, by Matthew J. Friedman, M.D., Ph.D. (Volume 351:75-77, July 1, 2004).  That article indicates that the incidence of PTSD increases with time after the trauma.  It also shows how widely the incidence figures can vary, depending upon the population being studied.  Therefore, the discrepancy between the 8-10% figure and the 17% figure probably is due to the effects of sampling differences, as well as the time factor. 

If we accept the assertion that women are more susceptible to PTSD,it is unclear why that would be.  One expert quoted in the article, Paula Schnurr, Ph.D., is leading a VA study of the problem; she happens to be a colleague of Dr. Friedman.  The final report has not been published yet, so it is difficult to so anything about the validity of their initial report.  She has found that a high proportion of women in military service have a history of exposure to violence prior to enlistment.  She speculates that, perhaps, many of these women enlist as a way of getting out of a violent situation at home.   Prior exposure to trauma is a known risk factor for PTSD. 

Another factor could be the difference between male and female veterans in their willingness to seek treatment.  Apparently, male veterans with PTSD are more likely to overcome the potential stigma and try to get help.  The Tribune mentions an unnamed  Defense Department study that indicates that women soldiers may be more reluctant to seek treatment because they had to struggle so hard to be allowed to get into combat situations. 
[...]That seems especially true of women, who have fought for years to be assigned positions in the Army that once were off-limits to them. A number of female Iraq war veterans suffering from PTSD declined to be interviewed for this article. [...]
This illustrates the significance of social context in the development of mental illness.  In general, persons who feel a sense of camaraderie probably have a lower risk; those who feel ostracized, or who worry that they might be ostracized, have a higher risk. There is a long tradition of camaraderie among male soldiers, but female soldiers are just now forming a cohort.

The Tribune article does have some information that may inspire hope.  In addition to citing the eight million dollar VA study on PTSD in women, they point out that progress has been made in finding effective treatments.  They report also that clinicians are getting better at case finding, which implies that fewer sufferers are going to go without treatment.  

The Sacramento Bee has a four-part series about women in the military (1  2  3  4).  The overall tone of the first article is positive, emphasizing how important it is for women to be able to serve, and citing many examples of women who have had positive experiences.  Many of the instances of negative experiences (cited in the second part) for women soldiers are the result of the actions of their male counterparts, not the result of combat.  The third part focuses on PTSD, providing some details that I would rather not know:
[...] "They'd never been away from home," she recalled. "Some were still living with mom and dad and then they were going off to war. I saw young girls just petrified. Other girls just lived to get drunk and get laid."

A born-again Christian, [Pamela] Schultz was appalled by what seemed to her the reincarnation of Sodom and Gomorrah:

Tents that reeked of alcohol, smoke and vomit. Couples standing cots on their sides to form an area for sex. Illegal affairs involving enlisted personnel, noncommissioned officers and officers. [...]
The final article in the series is about the effect of military deployment on the families of female soldiers.  It is not overly negative, although it certainly shows how rough it can be.  Although the connection is not made int he article, I suspect that the disruption of family life plays a role in the risk for PTSD.  A subsequent editorial highlights another issue:
Women in the military are twice as likely to be single parents as their male comrades in arms. Inevitably, long deployments for these young mothers means trauma for their kids.
A follow-up to the four-part series mentions another problem, one that probably increases the sense of ostracism for many female soldiers. 

A flier for a show aimed at boosting troop morale has had the opposite effect on some women in the military. Critics say it's totally inappropriate for a co-ed force and sends the wrong message to male troops. The Los Angeles performers are on a two-week tour of military installations in Kuwait and Iraq.
The point of the article is that the military leadership seems to collude with the tradition of emphasizing the needs of male soldiers, while discounting the experiences of the women soldiers.  Of note, the flier depicted above bore the email address of Halliburton Corporation.  The authors of the article had a hard time figuring out exactly who was responsible for the show. 
A representative of Armed Forces Entertainment, the unit that supplies acts and shows to all branches of the military, said the unit had nothing to do with booking the Angelz.

"We have a database of all our people, and I don't find them anywhere in it," said Air Force Master Sgt. John Martin. "The only thing we had that even remotely resembled that was "The Pinup Girls," and that was back in February of '04."
So they don't admit to hosting the Purrfect Angelz, but they do acknowledge being responsible for The Pinup Girls.  That makes me feel better.

Apparently, most of the entertainment provided for the troop in Iraq is not sexually oriented.  However, the fact that some of it is overtly demeaning to women is a matter of concern.  This seems to reflect the ambivalence in the military, and the civilian leadership, about gender issues in the military.  There are some signs that progress is being made.  For example, a new regulation increases the confidentiality of women who report sexual assault and harassment.  As mentioned previously, the VA is sponsoring a study of treatment for women soldiers and veterans with PTSD.  On the other hand, the latest Bush budget plan calls for increases in out-of-pocket expenses for veterans seeking care at VA hospitals and clinics.  While it probably is safe to assume that this would not affect those with service-connected disabilities, it is important to note that not all traumatized veterans will qualify for disability status.  In addition, there is rising concern about the impact of budget cuts on the VA health system.  John Kerry (remember him?) informs us that only half of VA medical centers have facilities for treating PTSD.  Blog for America mentions this:
In Michigan, thousands of Iraq veterans are on waiting lists to receive care. The government has also changed the criteria to disallow coverage of non-combat related injuries and medical conditions. Young people and reservists who risk their lives to serve this country are now unable to receive the most basic medical care.
Unfortunately, they don't tell us where that information came from.  A quick Google search, though, turns up this reference, from the  Swing State Project which cites an NYT article.  Swing State also lets us know that:
At least 250,000 veterans are forced to wait for their disability claims to be resolved by the Veterans Administration (VA). Sometimes up to two years. Despite the fact that thousands of veterans returning from Iraq will file disability claims, the FY 2005 budget reduces to number of staff responsible for processing those claims.
I suppose this does not really illustrate anything about poor treatment of women veterans.  Rather, it shows that all veterans can expect lousy treatment.   An editorial in the Boston Globe addresses this. 
[...]The goal of the administration, which has made similar proposals in the past, is to save close to a half-billion dollars by coaxing more than 200,000 veterans to seek care in other venues. But increasing numbers of older Americans have been turning to VA clinics and hospitals because they have lost their employment-based insurance and discovered that Medicare will not start covering prescription drug costs until 2006. Many of these veterans do not have affordable alternatives. According to Representative Stephen Lynch of South Boston, veterans in his district often have to wait eight months to see a doctor. [...]
More criticism can be found in the Congressional Record, which documents testimony pertaining to the impact of the new budget upon veterans. 
You don't have to take my word for this. Listen to the head of the VFW who addressed this issue in Commerce Daily a few days ago. John Furgess, who heads the Veterans of Foreign Wars, said the administration's proposed $880 million increase in veterans health care only amounts to an increase of about $100 million because the budget proposes that veterans shoulder a $250 enrollment fee and an increased copay on prescription drugs in addition to nursing home cuts. Furgess said:

Part of the federal government's deficit will be balanced on the backs of military veterans, because it's clear that the proper funding of veterans' health care and other programs is not an administration priority.
So most of the funding increase actually comes from fees paid by the veterans themselves.  That $100 million increase, by the way, is less than the cost of one day of military operations in Iraq. 

Not all commentators agree that there is a shortfall in treatment for veterans with mental illness, but this is controverted.  Although a 1996 law prevents the reduction of funding for specialized health care services in the VA system, there have been reductions in some locations.  According to the LA Times (free registration required):
A VA committee has found that the agency hasn't abided by that law. While VA hospitals may be treating more mentally ill patients, they aren't spending as much money doing so. At the West Los Angeles VA, the amount spent on mental health has decreased from $74 million in fiscal 1997 to $64.4 million in fiscal 2003, according to a national monitoring system.
The controversy, which probably reflects a nationwide trend, has to do with the shift of care from inpatient to outpatient settings.  Personally, I think the shift is a good thing.  People should not be put in the hospital unless absolutely necessary.  But the shift should not be used as an excuse to cut funding.  Rather, the cost savings from the reduction of inpatient care should be used to improve outpatient care.  Officials argue that, despite the overall cut in funding for mental health care, that outpatient services have been expanded, and the expanded services are adequate.  Critics counter by saying that the need for services in increasing faster than the capacity to provide those services.  Who is right?  From the LA Times:
A report last fall by the U.S. Government Accountability Office cited estimates that 15% of service members stationed in Iraq and Afghanistan would develop post-traumatic stress disorder. As of December, about 1 million troops had spent time in one of the two war zones (about one-third have done more than one tour).

The GAO determined that the VA did not have enough information to know if it could meet the increased demand.
Who is right?  It looks as though nobody knows.  In light of the information vacuum, I suppose the critics don't have much to go on.  But at least they can point out that there has been a lack of leadership.  Those who planned the war did not account for the aftermath of traumatized veterans; if they had, at least they would know if they could meet the increased demand for VA health care services.  As Rumsfeld might say, you go to war with the army you've got, and who cares what happens to them afterward?

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