Attrition: PTSD Predictor In Peril


June 16, 2010: The U.S. Congress is after the Department of Defense for not following up on PTSD (post-traumatic stress disorder) detection tests. Two years ago, Congress ordered a mental health evaluation for everyone in the army. Those who have not been in combat will serve as a baseline for comparing to those who have. In the last two years, the army developed a new program to accomplish this. This was to be accomplished by performing screening during the delivery of routine medical care, including annual checkups. The test was also to be given to troops before they went overseas, and when they came back. Initially, doctors were given a script that used some simple and non-threatening questions to discover if the soldier might have PTSD. If further questioning revealed there may be some PTSD, the soldier is offered treatment as part of regular medical care, not a special PTSD program. It was those programs that put off many troops, who wanted to avoid the stigma of mental illness. This screening procedure led to a computerized version of the test, which could be more easily administered. The army found that a reliable test could not be developed, and the one used had too many false positives to be useful. Congress did not want to hear this.

The army also wanted to find out to what extent non-combat operations (training can often be quite intense) can add to the stress that could eventually lead to PTSD. The basic idea here is to "mainstream" PTSD, trying to convince all the troops that PTSD is just another occupational hazard, not something you should try and hide, and hide from. You can't, and increasingly, the army won't let you. This effort was part of a wide trend in medicine, where better diagnostic tools enable diagnosing more people with problems that were largely ignored in the past. 

But the army finds itself facing several sources of PTSD. First, there was the discovery that many troops, because of exposure to roadside bombs, and battlefield explosions in general, had developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD. Thus there was an effort to document the connection between concussions, and other brain trauma, and PTSD conditions. There is a PTSD epidemic right now, created by the unprecedented exposure of so many troops, to so much combat, in so short a time. But what is actually happening is the discovery that much of what is thought to be PTSD, is actually physical injuries (to the brain) that can now be detected (with more precise instruments like MRI), and often treated.

Another problem was that nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention to civilian victims, via accidents or criminal assault), had made it clear that most people eventually got PTSD if they were in combat long enough. During World War II, it was found that, on average, 200 days of combat would bring on a case of PTSD. After World War II, methods were found to delay the onset of PTSD (more breaks from combat, better living conditions in the combat zone, prompt treatment when PTSD was detected). That's why combat troops in Iraq and Afghanistan often sleep in air conditioned quarters, have Internet access, lots of amenities, and a two week vacation (anywhere) in the middle of their combat tour. This has extended their useful time in combat, before PTSD sets in. No one is yet sure what the new combat days average is, and the new screening methods are an attempt to find out.

What the army does know is that a large percentage of its combat troops have over 200 days of combat. Some have three or four times that. So far, treatments (counseling and medications, for the most part) have worked. But these are not cures. A major reason for army generals talking about the army "needing a break" (from combat) is the looming loss of many combat experienced troops and leaders (especially NCOs) to PTSD. The army won't give out exact figures, partly because they don't have much in the way of exact figures. But over the next decade, the army will get a clearer picture of how well they have coped with PTSD, among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea or World War II.

The army is dealing with PTSD head on, believing that what happened in Iraq, will happen again, and now is the time to get ready. Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it, PTSD can often be treated, and its effects reversed. This has large ramifications for non-military medicine, for many civilians suffer from PTSD. That's because military recruits are screened for their ability to handle stress and resist PTSD. In the civilian community, there are far more people who can acquire PTSD after exposure to much less stress. The military believes they can detect trends in PTSD, and that will help in developing treatments, or ways to prevent the condition in the first place.





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