Re-Stressed-Out Vets?

(Weekly Standard)  This column was written by Sally Satel.

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"Dear Dr. Satel: You are an ideologically constipated coward." So begins one of several dyspeptic communications I've received recently from Vietnam veterans and others.

What provoked their ire was a remark of mine quoted in the Washington Post on June 20. Under the headline "Iraq War May Add Stress for Past Vets; Trauma Disorder Claims at New High," the article suggested that the current war is responsible for a surge in disability compensation among veterans' ranks.

While I do agree that current news coverage may prompt anxiety, sleeplessness, and distressing memories among veterans who have led productive lives since leaving Vietnam, I told the Post I was "skeptical" that veterans who had functioned well for three decades would now be permanently incapacitated.

My sentiments are unpopular — you "right-wing, bloviating [expletive deleted] pseudo-psychiatrist," wrote another reader on his blog — but my point is actually an encouraging one. That is, even if veterans are undone by news and footage of fighting in Iraq, few are likely to endure a subsequent lifetime of chronic anguish or dysfunction of the kind that requires long-term disability entitlement.

The technical term for such newly triggered incapacitation is "reactivated post-traumatic stress disorder," or reactivated PTSD. The clinical literature describes veterans of World War I, World War II, and the Korean War who, after briefly showing signs of stress disorders in the immediate aftermath of service, led productive lives for decades before breaking down in their sixties or seventies.

Clinical experience with such patients suggests that they can improve with treatment. The same is true of Vietnam veterans. When a traumatic event in civilian life causes a reemergence of PTSD symptoms, their response to treatment has generally been good. "There is no question that reactivated PTSD has been successfully treated," Matthew Friedman, a physician and the executive director of the National Center for PTSD, told me. "We know this from the patients' trauma and treatment histories."

And then there was the reaction to September 11. Veterans Administration medical centers in the New York area and even across the country had braced themselves for an influx of Vietnam and Persian Gulf veterans with reactivated PTSD. Yet researchers from the Department of Veterans Affairs Connecticut Healthcare System at West Haven, writing in the American Journal of Psychiatry in 2003, found no increase in the use of inpatient or outpatient mental health services at VA centers among veterans with a diagnosis of PTSD or any other mental illness in New York City or elsewhere in the United States in the six months after September 11. Another research team at the Bronx VA Medical Center did detect a rise but could not establish that it was actually due to the attack on the World Trade Center.

In yet another analysis, the West Haven team reported in 2003 in Psychiatric Services that "VA patients with preexisting PTSD were, unexpectedly, less symptomatic at admission [to hospital] after September 11 than veterans admitted before September 11, and patients who had follow-up assessments after September 11 showed more improvement."

What about after the Persian Gulf War? No data have been published regarding the pattern of compensation awards to Vietnam veterans in the wake of that conflict. It would be interesting to see the data, but unless they showed quite a large bump in claims, they would be hard to interpret, for a couple of reasons.

For one thing, the VA was increasing its funding of services and outreach to Vietnam veterans from 1988 into the early '90s. In addition, evaluating claimants' motivation years after their original trauma is rarely straightforward.

The VA is facing this very conundrum today. According to a May 2005 report from its inspector general, the department is now paying compensation for post-traumatic stress disorder to nearly twice as many veterans as it did just six years ago, at an annual cost of $4.3 billion. The vast majority of the recipients are Vietnam veterans in their 50s and 60s.

But how to distinguish between applicants who can be helped with short-term psychiatric care, those who are seeking a free ride and those who truly merit the diagnosis of chronic post-traumatic stress disorder (reactivated or not) and thus should receive long-term care and payments of up to $2,300 a month for life?

Among the latter are applicants who have "never been right," as their spouses often say, since their discharge from the military. They never regained their civilian footing and drifted further and further away from their families and communities. By the time they come to a veterans hospital for treatment, they are seen as having "malignant PTSD," that is, severe symptoms of post-traumatic stress disorder complicated by drug and alcohol abuse and other mental problems like depression. They are notoriously challenging to treat.

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[coulthardc]

Typical. Folks thinking veterans are faking to get money. I get $900 from VA for my combat-related disabilities, including PTSD, not $2,300 a month as mentioned.
The increase in Combat PTSD in recent years is due to VA finally acknowledging there is a real problem. Until then, if you went to VA to get help for PTSD, you could be locked in a mental ward for months or given mind-altering drugs. Not much of a choice and the vast majority of Combat vets just stayed out the system.
Most think of PTSD is an event-induced shock for which it takes time to heal. My own Congressman told me that he understood PTSD, because he had witnessed someone die in a car wreck.
Combat PTSD is about killing people. Until you kill someone, and do it intentionally, you have no idea what Combat PTSD is.
All my doctors at VA have been women from foreign countries who have zero experience in Combat. The last one could care less, as long as I'm there every six months to check in. The one before that was a young mid-20-year-old who was more interested in prescribing Prozak and Valuim then discussing my sleeping problem. Whenever the subject of killing comes up, they are swift to say that I was justified, because I was a soldier.
The problem lies in comparing standard PTSD to Combat PTSD. The reality is that there are thousands of good men who fought, shed blood and now live with horrific memories -- for this country -- who will never come forward.