Pervasive wound of war

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Two weeks ago, the President's Commission on Care for America's Returning Wounded Warriors issued its report to address major inadequacies in the military medical and benefit system first revealed five months ago.

The document details dozens of important recommendations and steps for action. However, significant problems still remain for the treatment of an often forgotten, yet pervasive wound of war — mental disorders.

The psychological health of America's military service members and their families poses a daunting challenge for the military community and our society. Of the veterans from Afghanistan and Iraq treated at government facilities as of November 2006, one-third were diagnosed with a mental illness. In particular, there is a pressing need to respond to the alarming prevalence of a complex illness that afflicts more than 34,000 Iraq and Afghanistan veterans — Post Traumatic Stress Disorder (PTSD).

PTSD is an anxiety disorder that develops in individuals who have experienced a traumatic event. The condition is typically characterized by a range of symptoms, including flashbacks, emotional numbness, depression, memory problems, and hyper-arousal. PTSD is a serious mental illness that without early identification and effective treatment, has the potential to be chronic, debilitating, and even lethal, with high rates of suicide.

The diagnosis of PTSD was first coined to describe this set of symptoms in 1980, but it is a young disease in name only. War veterans have experienced this disorder (often termed "shell-shock" or "war neurosis") throughout history, and the wars of the 21st century are reminding the world why. According to a 2004 study cited by the National Center for Post Traumatic Stress Disorder, 94 percent of soldiers in Iraq are the victims of what is termed "small-arms fire"; 86 percent knew someone who was seriously injured or killed; and 51 percent had handled or uncovered human remains. These traumatic experiences combined with long or repeated deployments in a politically controversial war make servicemen and women in Iraq particularly vulnerable to PTSD. In fact, 12 percent to 20 percent of returning soldiers experience PTSD, compared to about 5 percent in the general population.

The problem becomes even more complex in the context of women serving in the military. In their combat roles, service women in Iraq are subject to both violence from the war and assault from fellow service members or superiors. According to a 2003 study, about one-third of female veterans visiting the Veterans Administration for health care reported having been subject to rape or attempted rape during their military service.

The combination of sexual assault with the psychological trauma from combat known to contribute to PTSD in military personnel has created an environment in which an estimated 20 percent of servicewomen will develop this condition — 4 times the rate in the civilian population and more than double the rate of PTSD in male soldiers (about 8 percent).

Yet despite these alarmingly high rates of PTSD, the unique needs of servicewomen have not been adequately addressed. This lack of attention is significant given the recognition over the last decade of the inequities in women's health research and care and the importance of focusing on sex differences.

Finally, one of the most troubling effects of military-related PTSD is its chronic course. Studies have shown that with effective treatment and the passage of time, between 40 percent and 60 percent of those suffering from PTSD will recover. However, due to the nature of the disease, about 1 in 3 patients will continue experiencing some symptoms throughout their lives. Once veterans manifest chronic problems, their condition becomes more difficult and resistant to treatment, underscoring why it is vital to provide early intervention.

The commission's report addressed the pressing need to streamline veterans' care. In carrying out efforts to simplify access to services, it is critical that mental health needs of veterans are made a top priority. The report highlights the lack of mental health professionals to serve military personnel and their families, so it is essential that both the Defense Department and the Department of Veterans Affairs act quickly to rectify this deficiency. As of March of this year, only 27 of the 1,400 Veterans Administration hospitals and clinics contained inpatient PTSD centers and only two served women exclusively.

The combination of a lack of government facilities and mental health professionals trained to detect and treat PTSD underscores the urgent need to create a public-private partnership to provide our veterans with state-of-the-art care in their own communities, where the support of family and friends will be critical components of recovery. Congress is providing funding to advance veterans' health care, but much more needs to be done and vigilance is required to ensure the commission's recommendations are effective in healing emotional wounds of war.

But the fact is America really needs a fundamental alteration in how mental illness is viewed in today's society. Nearly 1 in 4 Americans will suffer from a mental illness annually, yet only a fraction will be accurately diagnosed and effectively treated.

In the coming 2008 U.S. presidential election, the candidates have a historic leadership opportunity to address mental health concerns. It's time for America to step up — for the health of her veterans and her public — and shatter the stigma that has all too long surrounded mental illness by providing parity in the diagnosis and treatment of these real, disabling disorders.

Susan J. Blumenthal, M.D., a retired rear admiral in the U.S. Public Health Service, was U.S. assistant surgeon general and deputy assistant secretary of health. She is a clinical professor of psychiatry at Georgetown University School of Medicine and Distinguished Adviser for Health and Medicine at the Center for the Study of the Presidency (CSP) in Washington, D.C. Elise Schlissel, a junior at Princeton University in the Woodrow Wilson School of Public and International Affairs, is a health policy intern at CSP.