VELANDY MANOHAR, MD,
DISTINGUISHED LIFE FELLOW,
PRESIDENT – ASIAN AMERICAN CAUCUS
09 22 08
I would like to offer a great variety of health promoting educational material culled from numerous references works as well as key web sites that may be of assistance to those who are committed to the health, safety, and wellbeing of our warriors, their dependents and families. Since the best results in a learning environment occur in the exchange of and reflection on information across the broadest spectrum, please feel free to send me additional information. Please write to me at my e-address to continue this bi-directional educational process and mutually beneficial enterprise.
I was unable to find specific information about the risk to post-partum mood and psychotic disorders among our women warriors even though I was able to find preliminary data on the higher risk of PPD (post partum depression) among the spouses of our deployed warriors. I did find data on the military sexual trauma program and details about an open study on rape. In addition, I have included sites with useful information on PTSD per se, the impact of PTSD on General Health of the individual and particular aspects of PTSD among women in the military. (These are not part of the body of this letter and are available as a separate package.)
I was unable to locate specific data about the impact on children at various age cohorts or stages of development of these multiple and lengthy deployment of one or both parents and loss of life or limb, death by suicide v. combat wounds of their parent or the worst-case scenario both parents. If the mate or parent was killed by friendly fire from members of the same unit how does the surviving spouse and the children manage their relationship with their natural support network of military families?
A great deal is being done, there is much that is known, but much more resources are absolutely essential to reach optimum level of care in terms of trained staff of various disciplines including case managers who can provide personal attention to the complex multi-factorial problems that must be addressed as soon as the men and women leave the theater of operations. More can and must be done to prepare our friends and neighbors in uniform before they are deployed to possibly minimize the very worst consequences of being in combat situations. Most of all the larger circle of friends and neighbors who are not in uniform the American public must be made aware of the various health, vocational, financial, family stresses that operate from day 1 of enlistment, during multiple deployments and during “dwell intervals” Our unfailingly generous nation I sense is concerned and willing to help if they were made aware of what needs have to be addressed and how best to offer the most helpful assistance to our Reserves, Guard and Active duty warriors and their families not in some remote place far from their homes but in their own communities surrounded by their friends and neighbors who can support and enhance the work of professionals engaged in the care of those who have borne the brunt of the battle as well as their families. A great American President said ..."Let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle, for his widow and orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and all nations.” A. Lincoln. II Inaugural address.
It became clear to me while I was doing the research for this material over the last two years that while we ramped up the training of our friends and neighbors to go to war we have fallen short, woefully short of placing the health care and social services organizational resources on a war footing to promptly, professionally and comprehensively offer integrated and compassionate care on an acute short term basis as well as over a longer term particularly during the transition of responsibilities for our friends and neighbors in uniform between the DOD and the DVA and to ameliorate the shock to the veterans and the community when they re-enter the civilian life they left behind before the stress and fog of war changed all of their plans and dashed their hopes in many cases forever. We have a responsibility to make sure there is a way back to the path that they were keen on pursuing before they heeded the call of duty, honor and country and placed themselves in harm’s way with debilitating consequences for all. Their loss is our loss. (Each and every one of us- make no mistake about this – we are all in this together for keeps)
THERE IS NO OTHER PUBLIC HEALTH MATTER IN AMERICA THAT SHOULD BE CONSIDERED A HIGHER PRIORITY THAN PUTTING THE HEALTH CARE AND SOCIAL SUPPORT SERVICES ORGANIZATIONAL RESOURCES FOCUSSED ON THE NEEDS OF OUR FRIENDS AND NEIGHBORS WHO HAVE DONNED THE UNFORM AND THEIR FAMILIES ON A WAR FOOTING.
I have addressed my readers as neighbors because I wanted to anchor the ideas and sentiments embodied in this letter on the core beliefs that are familiar to adherents of the three world religions: Judaism, Christianity and Islam who constitute most of the population of the USA. I have selected the two injunctions of the highest importance common to all three Faiths which appear in the Old Testament as well in St. Luke. (Luke 10:29-37). In their response to the “Common Word between Us and You “which was formulated by 138 Muslim Clerics and scholars from around the world the Yale Center for Faith and Culture offered the Christian response entitled “Loving God and neighbor together” selected these core principles. Dean H. Attridge, Prof M. Volf, Rev J. Cummings and Prof E. Townes are the authors of this inspirational document.
The two core principles are from Deuteronomy-the second law. The second source is the Leviticus. The third source is the Gospel of St. Luke. The dialogue which emphasizes these core principles occurs immediately before and is implicit the parable of the Good Samaritan.
The two pre-eminent principles are:
- Deuteronomy 6:5, “Thou shall love the Lord thy God with all thine heart, with all thy soul, and with thy might.”
- Leviticus 19: 17 and 18. “Thou shalt not hate any in thine heart: thou shalt not in any wise rebuke thy neighbor and not suffer sin upon him. Thou shalt not avenge nor bear any grudge against the children of thy people, but thou shalt love thy neighbor as thyself.
- St. Luke 10: 25, 26, 27, 28. “And behold a certain lawyer stood up and tempted him saying Master, what shall I do to inherit eternal life? Lord Jesus replied, “What is written in the law? How readest thou?” And he answering said, “Thou shalt love thy God with all thy heart, and with all thy soul, and all thy strength, and with thy entire mind and thy neighbor as thyself."
The parable of the Good Samaritan is a living breathing part of the Gospel of St. Luke (10:29) and is the response of Lord Jesus to this profound question from human consciousness, “Who is my neighbor?” LordJesus after setting the scene and the sequence of events in this parable asks another important question which must be reflected on, asked and answered every day by every person of the human race to the last generation. He asked, “Which of these three, thinkest thou, was a neighbor unto him that fell among the thieves?”(Luke: 10: 36.) The person who asked the question initially said,” He that shewed mercy on him.” Then said Lord Jesus unto him, “Go and do thou likewise.”(Amen) These sacred truths provide me guidance and support on a daily basis especially when I choose to address public policy issues and social justice that must be part of the dialogue the foundation and the scaffolding to support my endeavors and guide me as I formulate to the best of my ability and offer my perspective in a collaborative manner for review and response.
I would like to present these timeless touchstones of wisdom and refreshing springs of inspiration. Please drink deeply of at this oasis and return frequently for a sip because what follows flows from my pen and can leave you parched, high and dry in short order. (VM)
LIST OF RESOURCE MATERIAL: AS OF 09 12 08
Dana Gioia, Chairman of the National Endowment for the Arts writes in the Preface of “Operation Home coming edited by Andrew Carroll (the stories of battles in the Iraq, in Afghanistan and in the Homefront in the words of US troops and their families.) “" One cannot tell the story of a nation without telling a story of its wars, and these often-harrowing tales are most vividly told by the men and women who lived them. Today's American military is the best trained and best educated in the nation’s history. They have witnessed events that are changing both our nation and the world. Their perspectives enlarge and refine our sense of current history. It is time to let them speak.”
For this reason, I am recommending this book as well as “My hero- Military kids’ write about their moms and dads.” Allen Appel and Mike Rothmiller working through the Armed Forces YMCA have made a wonderful collection of 100 letters that illustrate vividly the emotional bond between kids, their moms and dads that is burnished in the crucible of war, through separation, sacrifice and suffering.
Aeschylus, “in war truth is the first casualty”
General J. Lawton Collins, “the most precious commodity with which the army deals is the individual soldier who is heart and soul of our combat forces.
Winston Churchill, “We shall draw from the heart of suffering itself the means of inspiration and survival.”
Helen Keller, “although the world is full of suffering, it is also full of those who are overcoming their suffering,”
In thy faint slumbers I by thee have watch’d and heard thee murmur tales of iron wars… Shakespeare, Henry IV part 1, act- ii, scene 3.
“There never was a time when, in my opinion, some way could not be found to prevent the drawing of the sword.” Gen. Ulysses S. Grant.
“I knew wherever I was, that you thought of me, and if I got in a tight place you would come - if alive.” Gen. William Tecumseh Sherman wrote in a letter to General Ulysses S. Grant.
Erasmus, “Dulce bellum inexpertis -war is delightful to those who have no experience of it.”
General Sherman, “there is many a boy here today who looks on war as all glory, but boys it is all hell.”
Lord Wellington during battle of waterloo, “nothing except a battle lost is half as melancholy as a battle won.” he defeated Napoleon decisively in that battle.
John. F. Kennedy, “any dangerous spot is tenable, if brave men – will make it so.”
General Sherman, “there are good corporals and good sergeants and some good lieutenants and captains, and those are far more important than good generals.”
Many of these quotations are culled from the excellent account of the battle that made the Viet Nam conflict an American War, “We were soldiers once… and young” by LT. Gen. Hal Moore (RETD) and Mr. Joe Galloway. I used this book also as a resource to grasp as best as I can the sheer terror and fog of war especially the breathtaking, bewildering pace of the brutal, mutilating, lethal individual physical combat that scarred everyone involved for life and close proximity of everything that is going on with ordinance crashing through the environment from close in rifles, machine guns and side arms, distant artillery batteries, mortar tubes, fixed wing aircraft and helicopters. The names of the 305 young heroes who died valiantly in the Pleiku campaign in Oct 23-Nov26 1965 are inscribed in the black marble Panel -3 East of the Wall. Lt. L. Geoghegan’s name is frozen in time beside that of PFC W. Godbolt the name of the soldier he died trying to save, bleeding into each others wounds and breathing their last breaths on a distant battlefield. Gen. Moore and Mr. J. Galloway asked this question in the epilogue of their book, “What would they have become, all of them, if they had been allowed to serve their country by their lives, instead of by their deaths?” As we take stock of what we observe and experience we need to pay special heed to these words.
SPECIFIC RESOURCE MATERIALS
“Except the Lord build the house, they labor in vain that build it: except the Lord keep the city the watchmen waketh but in vain.” Psalm 127(1).We have much work ahead of us. Let us strive on.
- American Psychiatric Association highlights MH problems of the combat veterans; psychiatric news 05 02 08. Information about MH resources for military personnel posted at www.healthyminds.org/military.cfm although their MH may be in jeopardy almost half of the military personnel said that seeking treatment for their MH problems would have a negative effect on their careers according to a survey conducted by APA. Additionally, 44 % of military personnel and 34% of their spouses said they avoided discussing any MH concerns they might have with other people. Military spouses reported feelings of significant stress caused by concerns about their loved ones serving far home, having to handle domestic pressures in various domains alone including unremitting vocational and parenting responsibilities. Only 44 % of the spouses believe the military cares about the MH concerns of their spouses and themselves compared to 60 % of their military mates. 68% of the military members and their spouses reported that there were not enough MH staff in Tricare (the insurance co. of the armed forces) to meet their mental health needs. Almost half of the military respondents agreed that taking care of their MH concerns was a low priority matter and 67% agreed that were only somewhat or not at all knowledgeable about warning signs of mental illness associated with their deployment.
- Deployments take a toll on soldiers and the providers. Longer deployments and not enough time between them are fraying the nerves of our armed forces. Aaron Levin-psychiatric news – based on us army’s fifth MH advisory team (mhat-v) redacted report is available at<www.army medicine.army.mil/news/mbat/mbat_v/mhat_v_oif and oef-redacted.pdf>
About 18% of army soldiers serving in Iraq screened positive for MH problems based on data collected Oct to Nov 2006. That figure rose to 27% for those on their third tour of duty. At the same time the troops stated that they had greater difficulty getting help for their MH concerns, while the personnel assigned to intervene with them complained of shortages in their ranks and more burnout. Major General Gale Pollack Deputy Surgeon General for Force Management stated "our goal is to get every soldier the health care he or she needs. ”Tours of duty lasted 15 months instead of 12 during the study. Soldiers on their second, third, fourth deployments were at increased risk for low morale, MH issues, and deteriorated functional status due to combat stress. SGTs and other non com officers who constitute the very backbone of our forces make up a larger segment of the army that is redeployed multiple times. 11% of them screen positive on the first tour. 27% screen positive on their third tour. Twelve months back home after 15 months in the theater is not sufficient time for our warriors to recover emotionally and physically.
About 15 to 20 % of service members are confronting other tough stressors –that of contemplating divorce or separation. This separation and isolation from family due to failed relationships is a critical factor in the suicide scenarios that preoccupy the minds of our warriors. Suicide ideation peaks in mid deployment and continues to rise beyond six-month point.
Soldiers who screened positive for MH problems such as depression, anxiety and acute stress were significantly more likely to engage in unwarranted and unethical conduct towards non-combatants (hitting and degrading them) and damaging private property while on patrol.
The MH staff that was surveyed included psychiatrists, psychologists, social workers, nurses, army MH specialists; they were short staffed, short on equipment. Their own mental wellbeing was poor, and their ability to do their jobs was compromised. Rithchie of the team that prepared the report stated, “Every year we have found problems and make recommendations to improve. But many psychiatric disorders, like PTSD may manifest later. So as a nation we must look to take care of our troops for the long term to prevent the problems that happened after the Viet Nam war.” The next item addresses the problems of PTSD and combat stress generated personal, social, family and vocational problems as well distrust of the military MH providers that interfere with reaching out for help.The two plays of Sophocles Ajax and Philoctetes illustrate these issues and Dr. Jonathon Shays two books; Achilles in Viet Nam and Odysseus in America are very helpful to explore and understand these issues.)
- Marines turn to Greek plays for PTSD – MSNBC.COM – A. P. 08 14 08
- “Warrior Mind Training “helps troops stay calm. AP-MSNBC 10 07 08. At Camp Lejeune, Fort Bragg and several bases in California our American warriors are learning the techniques that the Samurai used 1000 years ago to improve relaxation and concentration. These techniques are being used to proactively combat the development of PTSD and mitigate the effects of PTSD and TBI - At Camp Lejeune the USMC is offering this training through the “ Back on Track Program” offered by the Naval Hospital on the base. This training improves shooting range performance and raises training test scores indicating the warriors can be better prepared to adapt more effectively to the rigors of combat.
- Giving wounded warriors new hope- MSNBC.COM – Ron Mott- 04 10 08
- Tracking P-T stress in vets difficult-MSNBC.COM-R.Bazell-03 12
- In Iraq a head wound isn’t always a trip home-MSNBC.COM R. Bazell 02 27 07
- After initial brain injury damage continues-MSNBC- Linda Carroll-03 12 07
- The long road back after brain injury-MSNBC-L.Carroll-03 12 07
- Alcohol abuse rising among combat veterans-New York Times 07 08 08
- Waive medicare premiums for medically retired veterans- I-Gs of DOD and DVA- recommendations –Associated Press 07 09 08
- VA to review drug protocols for use of Chantix to treat Nicotine Addiction in vets with PTSD. APA headlines -07 10 08
- Children with parent at war vulnerable to anxiety and depression
- VA not meeting needs of military families- Associated Press(AP) 07 19 08
- Boys to men-why guys are not growing up?- Mike Kimmel-author –Guyland
- How hook ups and hang ups delay manhood-M. Kimmel- author-Guyland
- After the battlefield –fighting the war at home –New York Times series-“War Torn”
- Trauma related Chronic Pain, PTSD and depression appear to be linked.
- MIRROR THERAPY USEFUL FOR TREATING PHANTOM LIMB PAIN; Dr. J. Tsao of the Uniformed Services University of the Health Sciences and his colleagues at the Walter reed Army Medical Center as well as Malcolm Randall Veterans Affairs Medical center reported the results of a randomized sham controlled study of the effects of Mirror therapy on the severity of individual episodes and frequency of the episodes of distress due to phantom pain resulting from an amputated leg or foot in the November 22 07 issue of the NEJM. Not only did the two other experimental conditions not reduce the acuity or frequency of the pain but some of the individuals experienced more pain. Further when the individuals in the other two groups were switched over to Mirror therapy after a pre-set interval of time on the other two interventions, they experienced substantial reduction of pain. The underlying mechanisms need to be worked out but these positive results of Mirror Therapy have been reported by the pioneers in the study of Phantom pain- V.S. Ramachandran et al in 1996 issue of the Proc of Biol. Sci. 263: 377-386. This seems like an excellent technique to adopt across the military health care system especially since it is a well-designed controlled study of the response of our military personnel with amputations conducted by physicians familiar with injuries sustained by our heroes in military hospitals.
- DVA and SAMHSA sponsored Suicide hot line -50,000 calls -first year. 1200 vets saved.
- $3.1 billion (9%) increase on VA health programs- A.P. 08 01 08
- PTSD due to childbirth may be more common - Wall Street Journal -Zimmerman 08 05 08: Does this pose special risk for combat veterans and active duty warriors? (VM)
- Americans with chronic medical illness lack health insurance-NYT- Abelson, 08 05 08 Does this exacerbate existing adverse circumstances for veterans?( VM)
- History of psychiatric illness and substance abuse strongly predicts post- partum suicide attempts- Am. J. of Ob-Gyn Aug 08 -UPI report 08 08 08. Does this exacerbate risks for combat veterans and active duty warriors?(VM)
- War wives are at greater risk for postpartum depression (PPD) posted on 06 04 07 in perinatal mood disorders, Post Partum anxiety, Post Partum Depression, research, screening / permalink. Technorati tags: naval medical center, post partum depression, post partum progress, research risk, soldiers wives, and war wives. Denise Gellene of LA Times reports, “Women with spouses on military deployment during their pregnancies face a nearly 3 fold higher risk for PPD in initial screening tests. This study needs to be followed up. Dr. J. Millegan, co-author of the study presented at the APA meeting in San Diego recommended that military wives should be informed early in the pregnancy, screened for the risk and carefully monitored during the pregnancy and retested six weeks after their children are born.
- A. National Guard and Reserve warriors are more likely to develop drinking problems than active duty warriors. JAMA special issue 08 13 08- AP report 081308 B. Alcohol abuse and MH problems more common after exposure to violent conflicts. C. Child soldiers in Nepal and Liberia more vulnerable to PTSD, depression and suicide after sexual violence. Does this apply to Guard, Reserve and Active duty male and female warriors? ( VM)
- No credible evidence that a single abortion causes significant MH problems- American Psychological Association - was reported on 08 16 08 -Simon. Does this apply to combat veterans and active duty warriors?(VM)
- Pre-emptive actions may help co-workers MH and save lives- Forbes - Tara Weiss - August 08 13 08. Can this model be of help in Guard, Reserve and Active duty warriors?(VM)
- Multiple combat deployments may lead serious MH disorder, Substance Abuse and record levels of suicide attempts- USA Today 08 15 08 Elias.
- Suicide rates for young male Iraq and Afghanistan war veterans hit record high in 2006-DVA study ; USA TODAY (9/9, Zoroya) reports that "Suicide rates for young male Iraq- and Afghanistan-era veterans hit a record high in 2006, according to statistics to be released Tuesday by the department of veterans affairs (VA)." VA figures for "2006, the last year for which records are available," indicate that "there were about 46 suicides per 100,000 male veterans ages 18-29 who use VA services. That compares with about 20 suicides per 100,000 men of that age who are not veterans." The VA's records also "show those 141 veterans who left the military after Sept. "11, 2001, committed suicide between 2002 and 2005. in the one year that followed, an additional 113 of the Iraq- and Afghanistan-era veterans killed themselves." army psychiatrist Col. Elspeth Ritchie, M.D., M.P.H., explained that "lengthy and multiple combat tours in Iraq and Afghanistan cause relationship problems, a leading factor in suicides." the rate for young war veterans is nearly two and half times the rate for civilian males in the same age cohort.
- Suicide rates among veterans outpace national average across all age groups, VA figures indicate.
In continuing coverage from the Sept. 9 edition of headlines, modern healthcare (9/9, Dobias) reported that "suicide rates among veterans outpace the national average across all age groups, and the number is expected to climb, according to the veterans affairs (va) department." the VA's figures from 2006 indicated that "1,842 suicides" had taken place "among the men and women who had used the veterans' health system, an increase of 58 deaths, or 3.3 percent, from 2005." In addition, the VA's 2006 statistics suggested that "the suicide rate for men who were va patients between the ages of 18-29 was 45.82 per 100,000, compared with a national average for all men that age of 19.35 in 2005; 40.6 for ages 30-64, versus a national average of 23.19 in 2005; and 34.58 for ages 65 and older, compared with 29.53 nationally." To stem "the problem, the VA said it will implement...recommendations made to it by a work group on suicide prevention" to "better identify suicide risks," and to "improve its screening process for veterans with depression or post-traumatic stress disorder."
On its website, CNN (9/10,) notes that U.S. army officials "attribute the rise in suicides to anxiety and stress from increased operations and more deployments."
Panel praises VA’s suicide-prevention strategy. the ap (9/10) reports, "a blue-ribbon panel has praised the department of veterans affairs...for its 'comprehensive strategy' in suicide prevention that includes a 'number of initiatives and innovations that hold great promise for preventing suicide attempts and completions.'" called "the 'blue ribbon work group on suicide prevention,' the five-member group was composed of suicide prevention experts from VA, the Department of Defense, the Centers for Disease control and Prevention, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration." This group, which was created by VA secretary James Peake, made several "recommendations to further enhance" the VA's suicide prevention programs. One such recommendation was to improve the VA’s "screening for suicide among veterans with depression or post-traumatic stress disorder." the VA is currently "in the process of designing a new screening protocol."
- 22,000 veterans called the suicide hotline in its first year and approximately 1,221 suicides have been averted. A.P. reports 07 28 08. The hotline was created last July after years of criticism that the DVA was not doing enough to help vets. In April 2007 two vet groups sued the DVA for long delays in processing applications and receiving treatment. It receives 250 calls a day. Another hot line connected to the national suicide prevention life line received 55,000 calls from veterans and their families. National suicide prevention hotline is available 24 hours a day 1-800- 273-8255(talk)
Every year 12, 000 vets who are in the care of the VA try to take their lives.About 25 % of the vets who die by suicide everyday are under the care of the VA. About one vet an hour dies every day from suicide.
Rand Corp. report states 20% of troops returning from combat have PTSD sx and are at higher risk of suicide. Male combat veterans are twice as likely to commit suicide as non veterans according to research done at Portland State University. A former army medic Joseph Dwyer died of an overdose in Pinehurst N.C. on June 28, 08. He was photographed years ago carrying an Iraqi boy and running across a combat zone. For five years he lived in his private hell and had struggled with personal demons he tried to huff out of his head.The police had been sent to his home to relieve barricade situations evoked by the PTSD based memories of combat situations.
- Most vet suicides among Guard and Reserve troops. –AP 02 12 08. The members of the guard or reserve constituted 53 % of the suicides from 2001, when the afghan war began through the end of 2005. The tracking system in the DOD and DVA is poor and cannot be relied on especially in these very sensitive areas. The long tours and repeated deployments as well as rapid transitions take a heavy personal and family toll. In Nov. 07 President Bush signed a Joshua Omvig suicide prevention bill which directed the VA to improve its mental health training for staff and do a better job of screening and treating veterans. Mr. Joshua Omvig was an Iowa reservist who shot himself in front of his mother in Dec 05 after an 11 month tour of duty. Mr. Paul Rieckhoff executive director of Iraq and afghan veterans of America said the military has to screen guard and reservists three months after they return and develop more comprehensive interventions. To help the vets to transition more successfully to civilian life.
- Soldier suicide rate may set record again. Army: number of suicides per 100,000 could pass civilian population rate. A.P. 09 04 08 so far this year 62 of our warriors is dead by their own hand. Another 31 are being investigated as possible suicides. If these deaths are confirmed as suicide the number will outpace the record 115 suicide deaths in 2007. The rate of suicides among our bravest, brightest and the best among us will exceed that of the civilian population. To try stemming this inexorable tide the army continues to state that they are increasing the number of MH professionals as well chaplains.
The army is adding a new interactive video for troops and will be adding a new program to the basic training starting in January 09. A hotline started advertising in Washington area subway the slogan, “it takes courage and strength of a warrior to ask for help” the VA recently got more money to double their staff for suicide prevention and is planning on hiring 212 more staff. Number of suicides doubled between 2003 and 2005. It may double again between 2005 and 2008(every three years). The commonest method by far is by firearm which is 4 times as common as the next most prevalent method of hanging. Almost all of the successful suicides are committed by men. 118 of the suicides were among caucasians and 25 among non whites. Army had the heaviest loss of life from suicide probably half of all suicide deaths followed by Air force, Navy and least among the Marines. The active duty force had the highest number (50 % of deaths) followed by National Guard and reservist. Although the latter put together would cumulatively have the highest number of deaths by suicide.
- “After combat, soldiers turning to alcohol”-A.P. reports August 12 08. Guard and reserve combat troops are at higher risk than active duty soldiers. Dr. Edward Boyce of the VA Puget Sound health care system co-authored the study published in the journal of the AMA. The authors speculate that inadequate preparation for the stress of combat and reduced access to support services at home may be partly to blame. Mr. Bob Handy of the veterans united for truth which has sued the va to make changes in the MH systems of care stated, returning from war for guard and reservists is very different from going back to Fort Benning or Hood or Camp Lejeaune were everybody on your street is in the military. The Millennium study launched after the first Gulf War will continue to study the effects of combat on the lives of our warriors and their families. Alcohol abuse and other drug abuse including inhalants like Mr. Joshua Omvig, PTSD and depression/suicide constitute the iron triangle that severely handicaps the lives of our warriors and their families.
- Will the full 28 day dosing of oral contraceptives be more helpful than the 21- 7 day dosing regimen to alleviate disabling sx of premenstrual dysphoric disorder? David Rubio, md and Asad Meymandi, MD-UNC, Chapel Hill –August 19 08 headlines briefing by am. Psychiatric Association. Can Guard, Reserve and Active duty warriors be studied using these protocols? (VM)
- A. Are bi-racial Asian Americans twice more likely to be at risk for MH disorders than mono-racial Asian Americans in the military? B. Are family conflicts among Asian Americans in the military add significant risk for suicide? (Data on civilians suggest this according to UC- Davis researchers.)UPI reports 08 20 08.
- Invisible wounds hurt just as deeply. DOL website-“America’s heroes at work” toll free # 800-526-7234. This offers employers assistance to better understand and manage MH issues of returning warriors. Rand corp. study: 300, 000 veterans have come home with MH disorders and another 300,000 with head injuries based invisible wounds. Reservists and Guards may find transition to their civilian jobs much harder because of these invisible wounds. A small study using Functional MRI scanning is relevant to this domain. Health Day (9/11, Preidt) reported that the "brains of people who've recovered from head injuries have to work harder than the brains of healthy people to perform at the same level," according to a study published in the Sept. 9 issue of the journal Neurology. For the study, researchers at Canada's Rotman Research Institute used functional magnetic resonance imaging (fMRI) "to assess brain activity in" eight "recovered brain injury patients and healthy people while they did a mentally challenging task that involved control and manipulation of information held in the mind." Analysis of the "imaging data revealed that...patient brains had to work harder to perform at the same level as healthy, non-injured brains. Specifically, the brain injury patients showed a greater recruitment of regions of the prefrontal cortex and posterior cortices, compared to healthy controls," the authors explained.
UPI (9/12) reports that "suffering a traumatic injury (not necessarily TBI can have serious and long-lasting implications for a patient's mental health," according to a study published in the Annals of Surgery. For the study, researchers "tracked 2,707 injured patients from 69 hospitals across the country, and found 20.7 percent had" post-traumatic stress disorder (PTSD), "and 6.6 percent had depression one year after the injury." In addition, investigators discovered that "injured patients diagnosed with PTSD or depression was six times more likely to not have returned to work in the year following the injury."
- A growing flood tide of combat warriors is coming home to America with undiagnosed and untreated TBI. About 20 % or nearly 300, 000 have suffered at least one concussion. the TBI causes havoc in their own lives and in the lives of the people around them; family members, treatment staff, employers, social support networks leading to loss of autonomy, social connectivity and resilience and downward spiral into despair and demoralization and a number of additional morbidities with the adoption of self destructive behavioral repertoires to cope. DVA reports 15% of the 227, 000 warriors from Iraq and Afghanistan operations have screened positive for TBI since April 2007.
A big unknown: a vast number of service members who fought earlier in the war and those who have not come forward remain unscreened. Thus they and their wounds remain invisible. May be the toll free line of the DOL might help to reach these forgotten warriors. (VM). We need to also test the specificity and sensitivity of tools used in the previous screenings and compare it to other available batteries of tests to effectively screen and direct to specific care centers of excellence those who need specialized management. (VM)
- Tracking Beta Amyloid levels after acute brain injury can help to develop interventions that we can apply immediately after a traumatic brain injury and reduce negative long term outcomes including Alzheimer’s. Joint study between American and Italian researchers reported in journal science. Intra cerebral micro dialysis demonstrated that levels of beta Amyloid mirrored improvement of in the Glasgow coma scale. When the neurological status got better the levels increased, when the patients was getting worse the beta Amyloid levels trended down. Can this type of research be extended to medical facilities in theater of operations or secondary sites in Middle East or Germany to develop profiles that can predict specific outcome early and point to interventions that can prevent or lower morbidity and mortality? ( VM)
- Brain injured vets still not getting proper care: A.P. 05 01 08. Inspector General of VA studied the bush administrations long term efforts to support veterans with TBI, a leading problem among soldiers struck by IEDS. These injuries both visible and invisible result in lasting emotional and behavioral difficulties. The sample group received treatment in the VA initially in 2004. In the first report in 2006 the IG found significant gaps in follow-up care and counseling for family members- 16 months following treatment and recommended improvements. The key unmet needs are in these domains: primary and specialty care, family counseling, Depression, PTSD and anger management, vocational services and housing assistance. The VA pledged to coordinate care with the Pentagon. The most recent report concluded the VA was falling short for 25% of the TBI affected vets. The VA admits that the case management systems have been inadequate to ensure that all vets with TBI are being followed as their clinical needs dictate the process. The VA plans to call on 570,000 recent combat vets to identify gaps in service.
- Protection against genetic discrimination. A.P. reports on 08 29 08. The State of Illinois strengthened protections against discrimination based on the results of sophisticated genetic tests that can pinpoint someone specific risks for developing particular disorders to bring the state in line with the federal law and in some ways surpassing the Federal genetic information non-discrimination act signed by President Bush. Are the men and women in uniform and veterans subject to genetic testing that can be used in a discriminatory manner? Are they aware they are being tested or are the genetic data being gathered from samples already collected for legitimate purposes or surreptiously? Does the federal genetic information nondiscrimination act apply to veterans, national guard reservists and active duty combat warriors ?( VM)
- Cymbalta: a drug approved for treatment of depression, fibromyalgia, generalized anxiety disorder, diabetic peripheral neuropathy can relieve the symptoms of chronic low back pain as well according to 13 week study on non depressed adults presented to European federation of neurological services reported by web md 08 26 08. Chronic low back is an intractable disabling disorder. Veterans, Guard, Reservists and Active duty combat warriors may benefit in many different interactive ways by the use of this agent.(VM)
- Number of veterans suffering from undiagnosed mild traumatic brain injuries remains unknown. On its front page, the http://recp.mkt32.net/ctt?kn=7&m=2175630&r=OTE4MjY3OTU3S0&b=0&j=OTc4Nzk3MjAS1&mt=1&rt=0NYT (8/26, a1, Alvarez) reports that "a growing tide of combat veterans" is returning "home from Iraq and Afghanistan with mild traumatic brain injuries, or concussions, caused by powerful explosions. as many as 300,000, or 20 percent, of combat veterans who regularly worked...away from bases" may "have suffered at least one concussion, according to the latest pentagon estimates." the concussions may leave many with "longer-term problems that can include...persistent memory loss, headaches, mood swings, dizziness, hearing problems, and light sensitivity. these symptoms, which may be subtle and may not surface for weeks or months after their return, are often debilitating," and could lead "to financial problems, job losses, divorce, and mental-health issues." last year, the Department of Veterans Affairs began "screening all Iraq and Afghanistan war veterans who come in for clinical help. So far, 33,000 of 227,015, about 15 percent, have screened positive for mild brain injury since April 2007." It remains unclear, however, "how many service members, particularly those who fought earlier in the war, remain unscreened, and whose injuries go undiagnosed.”
- "Genes help explain post traumatic puzzle.” A. P. 03 18 08: A quarter of a million Americans are expected to develop PTSD at some point in their lives.
Though preliminary the ground breaking research published in the JAMA on 03 19 08 provides insight into the distressing and often puzzling and disabling condition that will afflict increasing number of combat troops and veterans. Researchers found that specific variations of a stress gene may be adversely altered in childhood due to abuse. This adverse alteration increased the probability of adult survivors with these specific variations to be extremely vulnerable to the risk of developing PTSD. The worse the abuse sustained in childhood, the stronger the risk of PTSD as adults. These variations as well as history of abuse among those with these variations can greatly influence how two people who are in same location can react very differently to an IED blast. One will regard it as a bad day at work and go back to fight another day but the other person may be consumed by severe emotional reactions.
- Suicide the fourth leading cause of death preceded by hostile action, accidents and illness. Suicide among regular army rose to 108 confirmed dead in 2007. a. p. 05 29 08. This happened during the most violent year in Iraq and Afghanistan. 25 % of the deaths were in Iraq. The deployments had increased from 12 months to 15 months. In 2004 there were 67 suicide deaths. It increased to 85 in 2005 and 102 in 2006.
Since the global war on terror began the army has lost 580 troops the equivalent of an entire combat battalion task force. LT. Gen. M. Rochelle directed the army website to post the best available information to raise awareness and reduce suicide among our best and the brightest.
- “43,000 deployed unfit for combat by the end of 2007.”Gregg Zoroya USA today 05 08 08. this is number is like the proverbial canary in the coal mine it is clear marker of the stress placed on human beings who are deployed to maintain an effective force in the theater. To date this has required the deployment of 1.6 million human beings dressed up and sent into harms way. Since 2003 more than 43,000 have been deployed to combat despite being classified as undeployable. The annual number fluctuated between as low as 5000 to as high as 11,000(almost) most of these troops were in the army. About 5-7 % of the troops in the active duty army, guard and reserve are rated as non-deployable. The commander makes the final decision according to the top military doctors in Walter Reed with respect to deployment, medication use and follow-up treatment of psychiatrically ill troops.
- Wartime PTSD incidence jumps to 38,000. Reuters 05 27 08. Multiple combat tours increase severity of symptoms. Incidence surged by 47% in 2007, bringing the five year total to more than 38,000. The number of new cases diagnosed in military facilities increased by almost 4,500 from 9,500 in 2006 to 14,000 in 2007. The marines reported 5, 6000, the army reported 28, 365. The Navy and Air Force are unprepared to place accurate and complete figures before the American public. DOD secretary gates announced a change in the US Govt. clearance process that allows PTSD affected warriors to seek help for combat related MH issues without risking their military careers.
The 38,000 mentioned is a low estimate because many warriors do not seek medical assistance for various reasons .The chief one is fear of baring ones soul due to stigmatization. Out of the 1.6 million troops who have deployed 18.5% according to the Rand Corporation experience symptoms of ptsd or depression a total of about 300,000 this number is provides added detail to the monumental scale of suffering caused by the two wars that have killed 4,600 of our best and brightest and wounded several thousand more including the more readily visible wounds and the invisible wounds of the 300,000 with TBI
- Gut check: Iraq war’s impact at home. Karl Huus MSNBC. 10 15 2007 this reporter puts a human face on the on the stark statistics showing that the military is stretched thin after more than 4 years in Iraq and 6 years in Afghanistan. . Repeated and lengthy postings and diminishing “dwell times” between postings have taxed the soldiers and taken a growing toll on the home front. Ms. Patricia Barron of the National Military Families Association says families are truly exhausted. They are feeling the stresses of separation more acutely. This extremely difficult position developed over time in large part due to the different approach Generals and Politicians took to provide manpower for the war. It differs from the approach taken during the Viet Nam war. (1964-1975). Then a much larger active military of 8.7 million troops was bolstered by the draft which added 1.7 million more to the ranks according to VFW. More than 670 000 of the draftees served in Viet Nam constituting 25% of the force stationed there. The draft ended in 1973. The active military dropped to 1.4 million according to DOD. In order to sustain troop levels in what has become a much more prolonged and protracted battle for survival than anticipated, the military has relied on repeated deployments and a far heavier reliance on the National Guard and reserves. In comparison to Viet Nam operations where 340,000 guard and reserve warriors were deployed over 434,000 guard and reserves forces have been deployed to Iraq and Afghanistan. Nearly a third more deployed in a third shorter period of war. Extended tours of duty of 18 months in the current operations is also a third longer than during Viet Nam where the standard tour was 12 months. Further a Guard or Reservist could not be redeployed to the theater for 24 months per army mandate.(Larry Kolb –Center for American Progress.) the strains of the long immersion in life and death situations are familiar to any one who has loved ones serve in an armed conflict. After a flood of damning press about treatment of returning soldiers, the military medical bureaucracy is beginning to ramp up to attempt to identify and mange the health needs and specific psychological issues of the warriors and their families according to the American Legion spokesperson Ms. Ramona Joyce. They were not prepared for the number and type of injuries.
But experts say according to Karl Huus that the uncertainty and fear felt by the family members in this war are amplified by how people are being called on and to what extent. A Gut Check reader who has a son in the theater for the second time says,” to have 1 percent of this nations citizens bear 100 % of the burden of the war on terror is morally reprehensible. “The slogan “Support our troops” needs to be more than words to the other 99% of this nation's citizens.” The mother of army SGT 1st class J.Miller, Ms. L. Stranlund says, “our experience is that it is two different worlds - one for every body else and one for the military families and service people.” About 155,000 children belong to families who have one or both parents deployed. The National Military Families Association launched Operation Purple- 34 free summer camps for these children designed to help them cope more effectively with separations, loss and with returning parents who are suffering from visible and perplexing invisible wounds of war. Army spec. Bridson’s (who was in Iraq for fourteen months at that time) ten year old son offers this prayer for his father and his family, “the light of God surrounds you. The love of God enfolds you. The power of God protects you… The American Legion is also actively extending assistance in the form of child care, to grocery shopping to military spouses and launching heroes to hometowns in 2005. This very worthy program provides severely wounded veterans with all the services they need to get them and their families back on their feet. Dan Caulfield, founder of <hireahero.com> and he a veteran says, “The military guys are in this world that is completely isolated, and the civilian society loses its touch with its military. He adds,” the good news is that social networking really can solve this problem… especially if you come from outer space, which is what the military is.”
- Iraq war strains army mental health system. Reuters 05 06 08. The military and its critics agree on one thing- there are not enough therapists to treat all the warriors who put their lives and limb on the line in the field of battle. The experience of the 10th mountain division according to Mr. P. Rieckhoff who founded Afghanistan Veterans of America serves as a canary in coal mine. They are a good barometer to understand the human cost of war. The 2 BCT is the most deployed brigade in the US Army since 2001. Another advocacy group Veterans for America spokesperson Adrienne Willis said even though we knew this group was coming home after their fourth deployment and there would a host of problems there was no system of care put in place to assess and address their concerns.
The staff at Fort Drum were not prepared to deal with the needs of 3, 500 returning heroes. These warriors had to be placed on waiting lists for two months. In addition their commanding officer General Oates reportedly decided to publish the names and photographs of the returning warriors who drank and broke the law in order to shame these heroes into sanity and sobriety. This is totally contrary to the position he has taken that psychological wounds are legitimate wounds sustained in combat conditions. This General may have violated Federal confidentiality laws 42 CFR that protects Americans who are suffering from alcohol and substance use disorders by publicly identifying them as such. (If the facts as stated are borne out) The spokesperson for Veterans of America Ms. Willis said, while nobody would justify drunk driving, it is important to examine the link between PTSD and substance use including drinking alcohol. The commanding officer was making the soldiers responsible for the psychological trauma acquired during the course of the theater operations when he placed his country first and his peers to the right, left behind and in front of him/her above his family and even himself. This type of punitive wrong headed actions by the commanding officer can inhibit and interfere with help seeking behavior that young warriors find so hard to acquire even when they are in desperate circumstances. Philoctetes a Sophocles play that is enacted in an innovative Marine Corps initiative to highlight the effect of PTSD highlights the feeling of abandonment of a greek warrior who was in dire need of help but was not able to psychologically transcend the chasm of distrust of the higher authorities in greek military.
- GAO study suggests DOD not tracking post-deployment mental-health assessments. Government Health IT (9/12, Buxbaum) reported that, even though the Department of Defense (DOD) "has the technology to track post-deployment mental-health paperwork soldiers are now required to file," its "oversight of those rules has been so sketchy that it has been impossible to evaluate the degree to which the service members are completing the forms," according to a study "conducted by the Government Accountability Office (GAO) and released Sept. 4." The GAO found that "DOD's oversight of its deployment health assessments does not provide DOD or Congress with the information needed to evaluate...the military services' compliance with deployment health assessment requirements."
There are two poems and a prayer that bring to the fore certain important components of the human equation influenced by War.
- Rudyard Kipling wrote the poem “IF" after his son perished in WW I. Mr. Kipling was a deservedly renowned poet and author who was an ardent Imperialist and unabashed supporter of the principles and practices that extended the hold of the British Empire. He vigorously pressured his only son over the objections of his son and Mrs. Kipling to join the combat units of the British military as did the cream of British Society of his day. I am sure such family circumstances occur to this day and will in the future. It will be important to identify, assess and address the impact of the death, PTSD and mutilation on all of the key family members.
- Commander Kelly Strong, USCG wrote the ballad “Freedom is not free” when he was in ROTC. This poem is a tribute to his dad who is a career Marine and served two tours of duty in Viet Nam.
FREEDOM IS NOT FREE
I watched the flag pass by one day,
it fluttered in the breeze;
a young Marine saluted it,
and then he stood at ease.
I looked at him in uniform,
so young, so tall, and so proud;
with hair cut square and eyes alert,
He'd stand out in any crowd.
I thought... how many men like him
had fallen through the years?
How many died on foreign soil?
How many mothers' tears?
How many pilots' planes shot down
how many died at sea
how many foxholes were soldiers' graves
No, Freedom is not Free.
I heard the sound of Taps one night,
When everything was still;
I listened to the bugler play,
And felt a sudden chill;
I wondered just how many times
That Taps had meant "Amen"
When a flag had draped a coffin
Of a brother or a friend;
I thought of all the children,
Of the mothers and the wives,
Of fathers, sons and husbands.
With interrupted lives.
I thought about a graveyard
At the bottom of the sea,
Of unmarked graves in Arlington.
No. Freedom is not Free!
- Finally General Douglas MacArthur wrote this prayer in the early days of the War in the Pacific. It was used during morning devotions as their credo. I include this prayer especially because the first several lines could if adopted by everyone go long way to overcome the resistance to seek help and follow through on assessments and treatments. This resistance has been detrimental across the board and has borne bitter fruit.
“ Build me a son, o lord , who will be strong enough to know when he is weak, and brave enough to face himself when he is afraid; one who will be proud and unbending in honest defeat, and humble and gentle in victory.
Build me a son who’s wishes will not take the place of deeds; a son who will know thee- and that to know himself is the foundation stone of knowledge.
Lead him, I pray, not in the path of ease and comfort, but under the stress and spur of difficulties and challenge. here let him learn to stand up in the storm; here let him learn compassion for those who fail.
Build me a son whose heart will be clear, whose goal will be high, a son who will master himself before he seeks to master other men, one who will reach into the future, yet never forget the past.
And after all these things are his, add, i pray, enough of a sense of humor, so that he may always be serious, yet never takes himself too seriously. Give him humility, so that he may always remember the simplicity of true greatness, the open mind of true wisdom and the meekness of true strength.
Then, I his father will dare to whisper, I have not lived in vain.
With respect to the various factors influencing health promoting and help seeking behavior in my experience a major factor that blocks these instincts for self preservation is the great deal of responsibility the well drilled warriors we send out in tightly cohesive units to battle perceives to be resting on their broad shoulders to protect the person in front on the back and to either side of each them, to leave no soldier behind, to hold the flag high on the field of battle and to carry out the mission of the unit to the best of their ability their last drop of blood and last breath. Gen D. Mac Arthur underscored the motto of West Point to make this point with these powerful words Duty, Honor Country. So to request permission to go off the line of battle or to admit any impairments what so ever that will weaken their squad, company or Combat team is a very tough decision. I offer these verses from the scripture to enable our committed warriors to step back and take care of their visible and invisible wounds and place the responsibility for the safety of their group and the success of their mission in the hands of God where it always rests.
I had incorporated these verses: Numbers 6:24, 6:25, 6:26, Psalms 44.3 and 127(especially127.1) to pay homage to the memory of a hero and offer worship to God Almighty for giving us even for brief shining moment this valiant son among so many more heroes who died for us on Iwo and other altars of freedom into my response to an essay written by John Rutherford of NBC News about this fact: 63 years after he helped to raise the Old Glory on MT. Suribachi Marine SGT. Michael Strank received his US citizenship papers. Sgt. M. Strank a hero of the flag raising event on Iwo Jima died tragically a few days later in action on a battle field where according to Admiral Nimitz, “Uncommon Valor was a common Virtue.” He is buried in Section 12 of the Arlington National Cemetery. . (Error! Hyperlink reference not valid. I offer you these verses which may help us all to recognize the often missed presence of God in our lives in the best of times and the worst of times, when we stand where it is brightest or when we are seemingly alone in the abyss of darkest despair. NUMBERS - 6:24 “The Lord bless Thee and keep Thee." 6:25 "The Lord make his face shine upon thee, and be gracious unto thee." 6:26 “And the Lord lift up his countenance upon thee and give thee peace." PSALMS: 44.3: " For they got not their land in possession by their own sword, neither did their own arms save them: but thy right hand, and thine arm, and the light of thy countenance, because thou hadst a favor unto them." PSALM 127.1: “Except the Lord build the house, they labor in vain that build it: Except the lord keep the city the watchmen waketh but in vain.”
There are times such as these when it behooves all of us to consciously make a decision to let go and let God, keep us guide us and save us from ourselves. So help me God to help myself and others. It is my hope that when the American People decide to focus our collective efforts to support our troops and their families fully they who have given their all will be able to achieve an equilibrium so evocatively articulated by Albert Camus, “In the midst of winter, I finally learned that there was in me an invincible summer.”L’Ete.
“You cannot choose your battlefield, god does it for you; but you can plant a standard where a standard never flew. S. Crane, “The Colors.”
“Only the dead have seen the end of the war.” Plato
Peter Yarrow of Peter, Paul and Mary wrote this memorable song“Light One Candle” Peter wanted to write a song that would be a call to peace and reconciliation. His words and music perfectly describe my personal responses to the harrowing and devastating experiences of our active duty warriors, Veterans, their dependents and families and the terrible personal cost of suffering, separation and loss exacted on our fathers and mothers, brothers and sisters, friends and neighbors because they chose to put themselves in harms way in Iraq and Afghanistan.
LIGHT ONE CANDLE
Peter Yarrow- ©1983 Silver Dawn Music ASCAP
Light one candle for the Maccabee children
With thanks that their light didn't die
Light one candle for the pain they endured
When their right to exist was denied
Light one candle for the terrible sacrifice
Justice and freedom demand
But light one candle for the wisdom to know
When the peacemaker's time is at hand
Don't let the light go out!
It's lasted for so many years!
Don't let the light go out!
Let it shine through our love and our tears.
Light one candle for the strength that we need
To never become our own foe
And light one candle for those who are suffering
Pain we learned so long ago
Light one candle for all we believe in
That anger not tear us apart
And light one candle to find us together
With peace as the song in our hearts
What is the memory that's valued so highly
That we keep it alive in that flame?
What's the commitment to those who have died
That we cry out they've not died in vain?
We have come this far always believing
That justice would somehow prevail
This is the burden, this is the promise
This is why we will not fail!
Don't let the light go out!
Don't let the light go out!
Don't let the light go out!
The final chants- “don’t let the light go out” merges in so well with the spiritual currents of Mahatma Gandhiji’s favorite hymn “Lead Kindly Light.” by John Newman. The last two lines of the first verse are: “ keep thou my feet, I do not ask to see the distant scene, one step enough for me Lead Kindly Light, Lead Thou me on.”
The last two lines of the last verse are also especially evocative in the context of this letter.
“To rest forever after earthly strife
In the calm light of everlasting life” Lead Kindly light, Lead Thou me on.
SEMPER FI, CARRY ON. Stay safe, stay well and stay in touch.
DISTINGUISHED LIFE FELLOW AM. PSYCHIATRIC ASSOCIATION, PRESIDENT, ASIAN – AMERICAN CAUCUS OF THE APA
ABPN B/C: ADULT PSYCHIATRY; ABPN B/C: ADDED QUALIFICATIONS ADDICTION PSYCHIATRY (RECERTIFIED 2003; ABPN: BOARD CERTIFIED-PSYCHOSOMATIC MEDICINE 2005, ABMS: BOARD ELIGIBLE-PAIN SUBSPECIALITY CERTIFICATION 2004; AMERICAN PSYCHIATRIC ASSOC: CERTIFIED IN ADMINISTRATIVE PSYCHIATRY; CERTIFIED BY SAMHSA /CSAT TO USE SCHED III, IV AND V OPIOID DRUGS; ABPN: EXAMINER, PART II ORAL EXAMINATION, ADULT PSYCHIATRY. NATIONAL BOARD MEDICAL EXAMINERS: CONSULTANT: USMLE II (STEP 2).
CT MEDICAL EXAMINING BOARD: MEMBER, UNTIL DECEMBER 07 CT.MEDICAL EXAMINING BOARD-NON BOARD HEARING PANEL MEMBER SINCE JAN 2008; CT. DEPT OF MOTOR VEHICLES COMMISSIONER’S MEDICAL ADVISORY BOARD-MEMBER
WHITING FORENSIC DIVISION-ADVISORY AND REVIEW BOARD MEMBER SINCE JAN 2008
CT. MULTICULTURAL HEALTH PARTNERSHIP - CT.DPH - CHARTER MEMBER SINCE JULY 08
ITEM 52 FROM PAGE 13-DEAR NEIGHBOR LETTER;
Following a story reported Tuesday in USA Today, the CBS Evening News (10/28, story 6, 2:05, Couric) reported that a new study indicates that "an alarming number of female soldiers have sought treatment for sexual assault committed by fellow soldiers."
The Los Angeles Times (10/28, Maugh) reported, "One in seven female soldiers who were deployed to Iraq or Afghanistan and later sought healthcare for any reason reported being sexually harassed or assaulted during their military service," according to a study conducted by Veterans Affairs (VA) researchers, and presented at a meeting of the American Public Health Association. "In contrast, only 0.7 percent of male soldiers reported similar experiences." Notably, "women who reported harassment or assault were 2.3 times as likely to suffer post-traumatic stress disorder (PTSD) as those who did not, and were also more likely to suffer from depression or engage in substance abuse. Men who reported harassment or assault were 1.5 times more likely to suffer PTSD or other disorders."
The study was "based on data from 100,000 veterans of Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom who used VA healthcare," AFP (10/29) adds. HealthDay (10/28, Dotinga), UPI (10/29), and the Newsweek (10/28) Soldier's Home blog also covered the story.
Too many soldiers in new care centers
Stricter screening procedures will stem the flood of patients
The Associated Press
updated 1:55 p.m. ET, Sun., Nov. 2, 2008
FORT CAMPBELL, Ky. - In a rush to correct reports of substandard care for wounded soldiers, the Army flung open the doors of new specialized treatment centers so wide that up to half the soldiers currently enrolled do not have injuries serious enough to justify being there, The Associated Press has learned.
Army leaders are putting in place stricter screening procedures to stem the flood of patients overwhelming the units — a move that eventually will target some for closure.
According to interviews and data provided to the AP, the number of patients admitted to the 36 Warrior Transition Units and nine other community-based units jumped from about 5,000 in June 2007, when they began, to a peak of nearly 12,500 in June 2008.
The units provide coordinated medical and mental health care, track soldiers’ recovery and provide broader legal, financial and other family counseling. They serve Army active duty and reserve soldiers.
Most injuries not severe enough
Just 12 percent of the soldiers in the units had battlefield injuries while thousands of others had minor problems that did not require the complex new network of case managers, nurses and doctors, according to Brig. Gen. Gary H. Cheek, the director of the Army’s warrior care office.
The overcrowding was a “self-inflicted wound,” said Cheek, who also is an assistant surgeon general. “We’re dedicating this kind of oversight and management where, truthfully, only half of those soldiers really needed this.”
Cheek said it is difficult to tell how many patients eventually will be in the units. But he said soldiers currently admitted will not be tossed out if they do not meet the new standards. Instead, the tighter screening will weed out the population over time.
“We’re trying change it back,” to serve patients who have more serious or multiple injuries that require about six months or more of coordinated treatment, he said.
By restricting use of the coordinated care units to soldiers with more complex, long-term ailments, the Army hopes in the long run to close or consolidate as many as 10 of the transition units, Cheek said during an interview in his Virginia office near the Pentagon.
In the past, a soldier with a torn knee ligament would have surgery and then go on light duty, such as answering phones, while getting physical therapy. But last October, the Army began allowing soldiers with less serious injuries such as that bad knee to go to the warrior units.
Expansion came amid Walter Reed problems
The expansion came in the wake of reports about poor conditions at Walter Reed Army Medical Center in Washington, D.C., including shoddy housing and bureaucratic delays for outpatients there.
Brigade commanders began shipping to the transition centers anyone in their unit who could not deploy because of an injury of illness. That burdened the system with soldiers who really did not need case managers to set up their appointments, nurses to check their medications and other specialists to provide counseling for issues such as stress disorders.
The Army’s goal now, as spelled out in a recent briefing given to Defense Secretary Robert Gates, is to screen out those who do not need the expanded care program, shifting them to regular medical facilities at their military base or near their homes.
Jon Soltz, an Iraq war veteran and chairman of VoteVets.org, said the Pentagon is making a fair argument. He acknowledged that some soldiers with less serious injuries might not need the units’ services.
Commanders need flexibility
But he said commanders need to be able to move their soldiers who cannot deploy due to an injury to the units because that is the only way they can get a replacement before going to war. Otherwise, the brigade goes to battle without the forces needed.
“The larger concern here is that the problem that is driving this is the manpower problem,” said Soltz. “The Army is overextended. We don’t have enough guys.”
It is vital; he said, that the medical system care for all the solders who need help and that any changes should not threaten that care.
Raymond F. DuBois, a former acting undersecretary of the Army and manpower adviser under then-Defense Secretary Donald H. Rumsfeld, said the units address “a problem that was not made aware at the highest levels” and do it well. But he has worried for months that the units were overstretched.
“Guess what? They did it so well everybody wants in,” said DuBois, now an adviser at the Center for Strategic and International Studies.
Cheek stressed that the new more stringent screening process will not deny care to soldiers in need or limit the treatment units to those with battle wounds.
“We don’t really care about the source of the wound, illness or injury. We really care about the severity of the wound, illness or injury,” said Cheek. “So if it’s a severe, very acute condition that needs rehabilitation and a lot of management and oversight, regardless of where it comes form, that soldier needs to be in this program.”
Patient load starting to decline
The latest data shows that it is working: The patient load is starting to inch down, from the peak of 12,478 in June to less than 11,400 in October.
Cheek estimates that the screening process will reduce the number to between 8,000 and 10,000.
As those numbers come down, the Army is also reviewing which units get more use. The list of potential closings include warrior transition units at Fort Rucker and Redstone Arsenal, in Alabama; Fort Leavenworth in Kansas; Fort Dix in New Jersey; and Fort Irwin in California. According to Army data, many of them either have only a dozen or so patients now, or can be combined with another nearby facility.
At Fort Campbell in Kentucky, however, more than 600 soldiers are in the treatment program. Staff there are bracing for a surge of patients when the three 101st Airborne Division brigades start returning home in the coming months.
Gen. Peter Chiarelli, Army vice chief of staff, toured the unit in late October. He gathered more than two dozen staff around a long table to hear their concerns about how the program is operating. Afterward he marveled that they talked not about their own administrative complaints, but about specific problems they were trying to solve for their patients.
In a small office down the hall, Lisa Gaines was blunt about what the unit meant to her.
“It’s done wonders for our family,” said the mother of five.
Healing physical and emotional wounds
Seated next to her, Spc. Sean Gaines nodded quietly as his wife talked about the strains his injury had on the family and how the staff worked to heal all wounds — physical and emotional.
Deployed to Iraq in 2004 with the 2nd Brigade, 101st Airborne Division, cavalry scout Gaines was shaken but not bloodied by the blasts of several car bombs and a house explosion. Yet when he returned home, he began having pain and his body went numb. The medical diagnosis was a crushed cervical disc — an injury he got either in Iraq or in training, only to surface later.
After surgery in October 2007, he came to Fort Campbell’s warrior transition unit — but he needed more than physical therapy. He had been told he could no longer serve as a scout.
“He loves the Army, he loves the military. For them to tell him he could no longer be a scout, it was difficult. It was a strain,” recounted Lisa Gaines. He was agitated, angry and withdrawn, she said.
In response, the warrior unit gave him underwater training as therapy for his injury, coupled with family counseling, budget management and career help.
“I realized I had options, I could continue to serve,” said Sean Gaines, who soon will leave the transition unit and take on a new Army job doing transportation management.
The counseling gave him time to figure out his options, come to terms with the change, and understand that he could either “drive on or prepare to exit,” he said.
He decided to go on, saying, “I am not going to be a scout, but I will still be part of a team.”
According to Army data, the key struggle is keeping the transition units fully staffed. In many of the more remote locations, Army leaders have trouble finding enough nurse case managers. As of the end of September, 12 of the units based at military posts were short those case managers.
Other locations, such as Fort Drum, N.Y., do not have enough behavioral health specialists.
Trying to ease shortages
Closing some of the locations may help ease those shortages, Cheek said.
“It shouldn’t be too surprising,” he said. “We’re 18 months old here, so now it’s time for us to relook at how we’re doing this, and where we can gain some efficiencies.”
He added that an order coming out in December will further refine the screening criteria for the transition units. In particular, it will call for the Army to identify other ways to provide care for reservists so they can receive the treatment they need closer to their homes, which often are far from large military bases.
The Army chief of staff, Gen. George Casey, has made it clear that any soldier who needs the coordinated care must get it, regardless of how many soldiers end up in the program.
Meanwhile, officials are building permanent care centers at the main bases over the next several years, at a cost of more than $1 billion. Annual operating costs are about $270 million, with the staff of about 3,000 consuming most of that expense.
Nearly 40,000 service members have been wounded in action in the Iraq and Afghanistan wars as of Friday, although more than 18,000 returned to duty within 72 hours of their injuries, according to Defense Department data.
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PSYHIATRIC NEWS; NOV 7 2008/PAGE 17: A.LEVIN: ROLE OF SOCIAL DEMOGRAPHICES STILL UNCLEAR IN PTSD. MORE NEEDS TO BE LEARNED ABOUT THE RELATIONSHIP OF SOCIOECONOMIC, ETHNIC FACTORS AND GENDER TO TRAUMA EXPOSURE AND RESPONSE. OTHER FACTORS DOCUMENTED IN PSYCHOLOGICAL BULLETIN NOV 2006 BY TOLIN,D.F. AND FOA,E.B ARE 1. SERIOUS INJURY, NUMBER OF TRAUMAS, LENGTH OF LAST DEPLOYMENTOFFICER V ENLISTED, DISCHERGED /RETIRED, RESERVE/GUARD, NAVY V ARMY AND AF V ARMY
PSYCHIATRY NEWS;:NOV 7 2008/PAGE 17: A.LEVIN: DEATH, INJURY TALLIES MASK TOLL ON FAMILIES’MENTAL HEALTH. TOO LITTLE RESEARCH EXISTS ON HOW PARENTAL DEPLOYMENT OR INJURY AFFECTS THE CHILDREN OF US TROOPS SENT TO WAR ZONES. THEY APPEAR TO BE AT RISK AT ALL POINTS BEFORE, DURING AND AFTER THEIR TIME IN A WAR ZONE AND AGAIN WHEN THEY ARE RE-DEPLOYED. TODATE MORE THAN 4100 HAVE BEEN KILLED AND OVER 30,000 INJURED. THESE NUMBERS POINT TO THE POTENTIAL FOR SERIOUS AND WIDESPREAD EMOTIONAL SEQUEALAE AMONG FAMILY MEMBERS AND DEPENDENTS OF OUR TROOPS.
PTSD AND POST CONCUSSIVE SYNDROME PRODUCES CHANGES IN PERSONALITY AND DYSCONTROL OF MOOD AND BEHAVIOR ( INCLUDING DOMESTIC VIOLENCE)THAT ADDS TO FAMILY STRESS THAT CAN LAST FOR MONTHS AND YEARS
ABOUT 73% OF ALL SINGLE MOTHERS ARE MOTHERS AND DEPRESSION RATES HAVE BEEN OBSERVED TO RISE AMONG DEPLOYED SINGLE MOTHERS, WITH INEVITABLE EFFECTS ON THEIR CAPACITY TO CARE FOR THEIR CHILDREN. (S. COZZA-USUHS) WIVES WHO WERE PREGNANT WHEN THEIR HUSBANDS WERE DEPLOYED FELT GREATER CONFLICT ABOUT PREGNANCY THAN WOMEN WITHOUT DEPLOYED SPOUSES. HOWEVER WITH COMMUNITY SUPPORT, ESPECIALLY FROM ON BASE SOURCES, HELPED THESE WOMEN. REPORTED IN RESEARCH IN NURSING AND HEALTH JUNE 2008.
AN ABSTRACT OF “THE RELATIONSHIP OF MILITARY IMPOSED MARITAL SEPARATIONS ON MATERNAL ACCEPTANCE OF PREGNANCY IS POSTED AT <www3.interscience.wiley.com/journal/117891890/abstract?CRETRY=1&SRETARY=0>
PSYHCIATRY NEWS: NOV 7, 2008/PAGE 16: A. LEVIN. USE OF PSYCHIATRIC DRUGS VARIES GREATLY ACORSS VET POPULATIONS-THIS RAISES QUESTIONS. MOHAMMED S ROSENCHECK.R REPORTED IN THE OCT 2008 ISSUE FO AM.J. OF GERIATRIC PSYCHIATRY THAT PHYSICIANS IN THE MH PROGRAMS OF VA PRESCRIBED PSYCHOTROPICS MORE OFTEN THAN THEIR COUNTERPOARTS IN THE PRIMARY CARE SETTINGS BUT UNLIKE THE LATTER THEY ( MH PROGRAM PHYSICIANS PRESCRIBED THSE DRUGS LESS AND LESS FREQ WITH INCREASING AGE.
AN ABSTARCT OF “ PHARMACOTHERAPY FOR OLDER VETERANS DIAGNOSED WITH PTSD IS POSTED AT
PSYCHIATRY NEWS: NOV 7, 2008/PAGE 16: A.LEVIN: “TOO FEW THERAPISTS RECEIVE COMPREHENSIVE TRAINING FOR TREATMENT OF PTSD. NEW TREATEMENTS FOR PTSD MUST BE DEVELOPED AND TESTED AND EFFECTIVE EXISTING THERSPIES MUST BE PLACED INTO WIDER USE. D. RIGGS, PhD”ALMOST ANY TREATMENT DELIVERED IN A CARING EMPATHIC WAY WILL HELP TH EPATIENT FEEL BETTER, AT LEAST FOR A WHILE. THE REAL DIFFICULTY IS HELPING THE NON REPSONDERS AND ENCOURAGING THOSE WHO ARE IN NEED OF TREATMENT AND ARE NOT ENLISTING IN TREATMENT PROGRAMS. (CONFERENCE COSPONSORED BY NIH, DEPT. OF VA, AND DOD’S DEFENSE CENTERS OF EXCELLENCE OF PSYCHOLOGICAL HEALTH AND TBI.