The Military Health System Blog
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Monday, August 18, 2008 – Rising to the Challenge of PTSD
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Posted by: S. Ward Casscells, M.D.
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I had the honor today of briefing Secretary Gates who asked for an update on the DoD programs on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). The fact that the secretary is serious about seeing improvement in these areas was brought home by the presence of each of the service chiefs and the service secretaries along with the vice chairman of the Joint Chiefs of Staff and the Undersecretary for Personnel and Readiness and the General Counsel.
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We are committed to promoting psychological health from start to finish. A new recruit says to himself or herself, "I’m going to get an education and some new skills" (and say to themselves, "I’m going to get a second chance"). The father says to himself, "They’re going to make a man of him," and the mother hears, "they are going to take care of my son (or my daughter)."
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In order to fulfill these promises, and in order to better predict who should be guided into what military specialty (so a person who would make a good computer technician is not guided toward the infantry and the person who would make a good chaplain is dissuaded from becoming a Ranger or SEAL) we need a fuller characterization of each recruit. We are beginning to pilot these kinds of studies so we can get a better picture of people’s educational and medical history, their family history, their goals, their hopes, their fears and their dreams. This way we’ll know who needs special monitoring and we’ll also be able to measure their growth in skill, leadership ability and confidence.
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We also need better ways of monitoring people during their deployments and during their careers in general. One of the things we need to look at is whether an annual questionnaire is as good as a real physical exam where a real doctor or nurse puts their hand on your shoulders and looks you right in the eyes and asks: "How are you doing?" "Do you ever feel overwhelmed?" Or, "Are you coping OK?" "Is your family OK?" I know from 30 years of being a doctor that these questions often lead to misty or averted eyes or a catch in their throat, and this is a chance to help.
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We recently looked at this issue from the standpoint of the most serious complication of depression or PTSD–suicide. This is an area where we have more work to do because it so often is unexpected. We’ve learned that, among our deployed troops especially, suicide is usually the result of a failed relationship and a sense of hopelessness and helplessnes; less often it results from financial stress, or a failure in performance by the service member, or abuse of the service member.
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A number of family programs have been instituted under the leadership of Ms. Leslye Arsht and a great deal of effort has been put into the evaluation of these programs. One of the programs that appeals to me was the Air Force demonstration I saw in Qatar earlier this year which basically showed couples how to discuss without fighting or at least argue without divorcing. Related classes were on such topics as dealing with his, hers, and ours families, and so forth. The program has a great track record and I have commended it to the other services.
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Also reassuring is the fact that surveys over the past year have indicated that we are beginning to reduce the stigma that has so often kept people from asking for help. It is noteworthy that some of the line leaders and even general officers have come forward with stories of their own stress or depression. And I’ve done the same myself. Secretary Gates and GEN Casey have recognized that shorter tours, and more time between deployments, will almost certainly help. As will the revision of the question on the security clearance form, so that marital counseling, for example, does not preclude getting a security clearance.

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Secretary Gates stressed the importance of our NCOs and other leaders getting the word out that it takes strength to ask for help, that "no battle buddy left behind" refers not only to physical injuries, but to combat stress.
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The mental health task force last year noted that we are short on psychiatrists, psychologists, social workers, psychiatric nurse practitioners and other counselors. We at Health Affairs, along with the Army, have worked hard at this over the past year and I’m happy to say that we have added approximately 244 mental health workers to the military treatment facilities (including PROFIS counselors)–nearly 50 through the public health service and over 5,000 at TRICARE.
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Perhaps more important is that the combat lifesaver course offers Battle Mind training. Getting this training out to every soldier, sailor, airman and Marine is critical to early intervention, so that small problems don’t impair performance, leading to much bigger problems. We need the battle buddy to notice when someone has a long face or a short temper or has quit laughing at the jokes that make others laugh or not eating etc… Someone has to tell them, "If you’re not going in to see the chaplain or counselor, I’m taking you."
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Now, in doing this we have to be sure not to feed the misperception that our warriors come home broken or dangerous when most come home stronger, wiser and more confident. They neither need nor want pity, just respect. Those in the Reserve and Guard want their jobs back. Those who enter the civilian world want and deserve leadership positions. Of the 10 percent or so who have PTSD, most will recover with time, patience and love. Some will need more. Let me conclude by saying that PTSD and other aspects of combat stress are, like head injuries, daunting challenges, but I’m proud to say that the uniformed military, DoD civilian, medical and line leaders, and our VA counterparts, are all working these issues with an intensity and a good will that are bound to result in improved care.

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