On a recent flight home, I was reading through a folder of information on posttraumatic stress disorder (PTSD) to prepare for this editorial, when the folder fell and papers scattered under the seats. As the man beside me helped me retrieve them, he said, “I couldn't help peeking at what you're reading. I'm a Vietnam vet—did two tours.” We spoke a bit about his experiences. He told me he had been an officer in command of a unit, and that he'd been wounded and sent home before his second tour ended—but not before he saw too many young soldiers “damaged.”
I asked him what he thought of the high rates of PTSD and mental health issues among new veterans. He leaned over the armrest and said, “If they really want to prevent PTSD, they shouldn't send anyone under the age of 21 into combat. Before that, they're too young and they don't know what it really means to have to face death or cause death. I'm no expert, but I think it's child abuse.”
Research seems to support my seatmate's assertion. Donna Sabella, contributing editor and coordinator of our column Mental Health Matters, focuses on PTSD this month (see “PTSD Among Our Returning Veterans”). She cites several studies indicating that younger soldiers, especially those under age 25, are at higher risk for developing PTSD. And it's well known that PTSD is often associated with alcohol and drug abuse, homelessness, depression, suicide, domestic violence, and occasionally violent behavior toward others. The figures are daunting: a July 2012 report from the Institute of Medicine states that, of the more than 2.6 million U.S. service members deployed to Iraq or Afghanistan since 2001, an estimated 13% to 20% “have or may develop PTSD.” The report, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment—the first of two mandated by Congress—reviews the relevant literature on PTSD and available options for prevention and treatment. But while help is available through the military services and the Department of Veterans Affairs health care system, many veterans who need help aren't receiving it.
All returning soldiers are screened for PTSD; those who seek services at Veterans Affairs primary care facilities are also screened at their initial appointment. Multiple treatment modalities are used, from cognitive behavioral therapies (including imagery rehearsal therapy and exposure interventions) to various other psychosocial, pharmacologic, and complementary therapies, many of which lack strong evidence supporting their use. But many veterans either don't seek care for PTSD or don't follow through with treatment. One 2010 study found that, of Iraq and Afghanistan war veterans newly diagnosed with PTSD, fewer than 10% attended the recommended number of counseling sessions within the first year of diagnosis.
Many veterans have turned to service dogs, such as the one pictured on this month's cover (see On the Cover). Veterans report that the dogs help them feel safer and calmer and help decrease PTSD symptoms. Until October 5, the Department of Veterans Affairs funded their use; now, citing a lack of evidence, it will fund service dogs only for veterans with visual, hearing, or mobility problems, and then only if the dogs are certified by one of two agencies. (The new rule will not apply to veterans who already have service dogs.)
There has been a groundswell of protest from veterans and groups who supply or support the use of service dogs for veterans with PTSD. The Department of Veterans Affairs is currently involved in a three-year study evaluating the use of service dogs for veterans with mental health disabilities, but until results are in, it will no longer fund such use.
Meanwhile, thousands of U.S. soldiers will soon become veterans, and if the data are correct, almost one-third might come home “damaged.” We owe it to our veterans to help them seek and gain access to a full range of health care services, including some for which perhaps we lack definitive empirical evidence. In the interim, we need to respect and support veterans’ choices regarding comfort and healing.