Invisible Wounds

Soldiers are coming back from Iraq and Afghanistan with post-traumatic stress disorder and other problems. Is the Veterans Affairs Department ready?

Abbie Pickett got home last April. During 11 months serving in Iraq as a specialist with the Wisconsin National Guard, the 22-year-old managed to avoid physical injury. But she didn't make it out unscathed. One event haunts her.

It happened late in October 2003, at a base near Baquabah, about 40 miles northeast of Baghdad. She quickly left a building when it shook under a mortar attack. "Someone ran out of the building yelling for a medic, and I ran in," says Pickett, who was a combat support engineer. "I was probably the first person in there." A soldier she hadn't met before was badly hurt; she tried to give him first aid, but it seemed certain he would lose his arm.

Pickett learned months later that the soldier had fully recovered and gone back to war, but the memory stayed with her. "I was very jumpy," she says. "I'd have panic or anxiety attacks at weird places where it was crowded, like the grocery store. Something just didn't feel right." Thoughts of the attack flooded her mind when she didn't want to think about it. She felt depressed. At times, she couldn't summon any emotion at all, while at other times she would become upset for no reason.

Last summer, Pickett sought help at the Veterans Affairs Medical Center in Madison, Wis. She saw a psychologist and a psychiatrist and in July was diagnosed with post-traumatic stress disorder. The condition causes people to relive a life-threatening or otherwise violent event to the point where it impairs their ability to function. Post-traumatic stress can last indefinitely and sometimes doesn't begin until long after the triggering event. People who suffer from the condition have high rates of depression, substance abuse, divorce, unemployment and other problems.

As soldiers return from Iraq, the Veterans Affairs Department is getting ready to treat many who have post-traumatic stress and other combat-related mental health problems. "We are preparing for an increase," says Dr. Terrence Keane, director of the behavioral science division at the National Center for Post-Traumatic Stress Disorder, a research consortium of seven VA facilities. "We hope we prepare without reason."

Unknown Toll

Veterans like Pickett aren't coming to VA for mental health treatment in large numbers-yet. "It's at best a trickle at this point," says Dr. Bruce Kagan, a staff psychiatrist at the Greater Los Angeles VA Health Care System. "Our experience from Vietnam and the first Persian Gulf war is consistent with this. We're seeing a relatively small number of people looking for treatment in the immediate aftermath of the war."

By mid-March, about 17,000 veterans, or 6 percent of those back from Iraq and Afghanistan, had sought psychological services at VA health facilities nationwide. Of those, 7,000 were diagnosed with post-traumatic stress; others experienced general anxiety disorder, depression, substance abuse, difficulty adjusting to life at home and other problems. Because VA provides treatment for post-traumatic stress to about 250,000 veterans annually, the Iraq and Afghanistan veterans represented only a small increase in the workload. Others get help at VA's community-based veteran centers.

This could change. "The most powerful predictor of mental health problems is the intensity of the war, and this is a very intense war," Keane says. Another factor: Improved surgical techniques and field hospitals located closer to combat mean more soldiers are surviving life-threatening injuries and then developing psychiatric disorders.

Seventeen percent of soldiers who served in Iraq and 12 percent who served in Afghanistan showed signs of major depression, generalized anxiety and post-traumatic stress, according to a report published in the New England Journal of Medicine in July 2004. More than 1 million troops have served thus far in those operations.

An editorial in the journal argued that the report might have underestimated the problem because the nature of the war shifted and not all disorders are immediately apparent. Steve Robinson, executive director of the National Gulf War Resource Center, an advocacy group based in Silver Spring, Md., agrees. "That study was done at a time when combat was relatively flat and stable and the insurgency had not kicked in," he says.

On the other hand, the study surveyed only combat infantry units. Not all soldiers sent to Iraq and Afghanistan are as likely as they are to experience intense combat. And because soldiers were surveyed shortly after deployment, it's possible that not all conditions detected will persist. "Many people exposed to events such as combat will experience these symptoms initially," says Richard J. McNally, a psychology professor at Harvard University and a post-traumatic stress expert. "Most of the time, the symptoms will eventually wane, weeks or months afterward."

Still, the numbers in the New England Journal of Medicine are the most authoritative available, and VA is using them as a guide. The department expects about 15 percent of Iraq and Afghanistan veterans to experience post-traumatic stress and other combat-related mental health problems, according to Dr. Mark Shelhorse, VA's acting deputy chief patient care services officer for mental health. Many veterans seek care outside VA through their private insurance, but the department still expects a large influx of mental health patients.

Vietnam's Lessons

In medical terms, post-traumatic stress disorder is relatively new. "I think people have been describing post-combat trauma back to the 'Iliad,' and even in the Bible," says Dr. Joseph Westermeyer, chief of psychiatry at the Minneapolis VA Medical Center. But rigorous scientific study of the disorder, which began after World War II, didn't gain much attention until after the Vietnam War. "It was only in the diagnostic nomenclature since the 1980s," Westermeyer says.

It was the generation of veterans who had faced guerrilla-style warfare in Vietnam, and hostility at home, that raised awareness of the psychological wounds combat can inflict. "When Vietnam veterans first came back in the '70s, we didn't really know what [post-traumatic stress disorder] was," says VA's Kagan in Los Angeles. "After a lot of initial mistakes, VA eventually developed a lot of treatment programs." By then, however, many Vietnam veterans had slipped through the cracks.

Between 1986 and 1988, VA conducted its National Vietnam Veterans Readjustment Survey of more than 3,000 veterans. Roughly half had "clinically serious stress reaction symptoms" and nearly one-third had post-traumatic stress disorder at some point. Fifteen percent of men and 8 percent of women were diagnosed with post-traumatic stress disorder at the time of the survey-more than a decade after coming home.

"The consequences of that were so horrendous that everybody wants to try to do better," Westermeyer says. Nearly half the male veterans with post-traumatic stress at the time of the survey had been arrested at least once; more than 10 percent had been convicted of felonies. Four out of 10 had problems with alcohol, and four out of 10 had been divorced. "We still feel it today," says National Gulf War Resource Center's Robinson. "You go to any VA medical center and the majority of people you're going to see right now are Vietnam veterans."

Among the lessons VA learned was the importance of outreach and of treating people as soon as possible. Veterans of the operations in Iraq and Afghanistan are entitled to two years of VA medical care, regardless of whether they have a service-related condition. They can seek treatment for mental health problems at VA hospitals and outpatient clinics, or receive readjustment counseling at the 206 veteran centers staffed by interdisciplinary teams. For the most severe cases, VA operates five inpatient post-traumatic stress disorder units and 14 residential rehabilitation programs.

"The secretary has mailed hundreds of thousands of letters telling [Iraq and Afghanistan veterans] about things they might experience, how they can access services, how to go to the VA Web site," VA's Shelhorse says. Veterans who visit any VA health facility are screened for mental health problems. In addition, each facility has a coordinator for Iraq and Afghanistan veterans, and mental health providers say there is an unofficial policy of giving priority to recent veterans-if not on the same day they call or come in, at least within the week.

Stretched Thin

Despite the unofficial policy, Iraq veteran Pickett has had difficulty getting in to see her psychiatrist. "I missed an appointment at the beginning of the year, and they said they would contact me with another appointment," she says. By May, she still did not have an appointment scheduled. Research shows that the most effective treatment for post-traumatic stress disorder involves 10 to 20 therapy sessions over the course of about three months, says Harvard's McNally. Between July and May, Pickett saw her psychiatrist about three times.

A 2004 report by the undersecretary for Health's Special Committee on Post-Traumatic Stress Disorder indicates such problems might be widespread. "VA must meet the needs of new combat veterans while still providing for veterans of past wars," the report stated. "Unfortunately, VA does not have sufficient capacity to do this . . . PTSD services had been steadily losing capacity even before [the Iraq and Afghanistan wars] began."

The Government Accountability Office found in a September report that officials at six out of seven VA medical facilities expressed concern about their ability to treat more patients with post-traumatic stress. The report (GAO-04-1069) said VA lacks adequate data to accurately project the future need for counseling and psychiatric treatment. VA officials dispute this finding. "We've got pretty good ideas from Vietnam on what to expect in terms of percentages," Shelhorse says.

He points out that VA allocated an additional $100 million this year and $200 million in fiscal 2006 for mental health, including $5 million each year for Iraq and Afghanistan veterans and millions more for post-traumatic stress teams and substance abuse treatment. "Our ultimate goal will be to have a clinical team at each medical facility," he says. Critics say that's overdue.

Veterans advocates and some VA employees say the department lacks the resources it needs to expand mental health treatment to a new population of veterans. "Very few people on [Capitol Hill] want to spend money on veterans' issues at this time," says Paul Rieckhoff, an Iraq veteran from the Army Reserve and founder of Operation Truth, an advocacy organization based in New York for Iraq and Afghanistan veterans. "I think they're having a hard time admitting the amount of damage that is being inflicted on the American soldiers and their brains."

Giving priority to Iraq and Afghanistan veterans without adequate resources has meant longer waits and fewer appointments for veterans from other wars, Robinson says. "Everywhere I've been, there's been a reduction in services." He has met recently with veterans and VA health care providers in Oregon, Florida, Georgia, New York and California.

"We've got our head barely above water," says a psychiatric nurse specialist at a VA facility in California who asked to remain anonymous. "If you get a couple of [Iraq and Afghanistan veterans], you basically have to send your scheduled patient home, which doesn't make any sense because your scheduled patient might be suicidal," he says. "What has really dramatically changed is how often patients are seen. I have patients who should be seen more often who I can't see." His facility also has trimmed costs by limiting certain expensive medications and relying more on group therapy.

"This has been a difficult time," says VA's Kagan in Los Angeles. "There has been significant budgetary pressure on us, and we're trying to do more with less-to see more patients with fewer resources."

At the Minneapolis VA Medical Center, the psychiatry staff has shrunk about 10 percent through attrition in the past two years and the workload has grown about 5 percent in fiscal 2005. "The staff just works harder," says Westermeyer, the chief of psychiatry. "If we don't get funding, I don't know what we'll do."